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PubMed1988

Is there a religious factor in health care utilization?: A review.

This paper reviews more than 30 studies of health care utilization in which the effects of religion variables are examined, an area previously unreviewed. The authors found that over three-quarters of these studies reported significant religious differences in rates of utilization. The most common operationalization of religion was religious affiliation (typically Protestant vs Catholic vs Jewish), although the effects of religious attendance and religiosity were occasionally examined. Most major areas of health care use are represented in this literature, including psychiatric care, maternal and child health services, dental care, and physician and hospital utilization. Despite the preponderance of significant findings, it is difficult to isolate any consistent trends, although low-order analyses seem to suggest that Jews are higher utilizers than non-Jews. New findings presented from a study in Appalachia were inconclusive. The authors discuss the conceptual limitations inherent in ways in which health services researchers typically investigate the effects of religion. Drawing on recent work in the epidemiology of religion, several recommendations are offered regarding the prospect of future research in this area.

Appalachian Region↗
PubMed1997

Predicting psychiatric emergency admissions and hospital outcome.

OBJECTIVES: A decision support tool for psychiatric hospital admissions was developed and validated to provide reliable, clinically relevant information to providers and case managers. METHODS: Using the Severity of Psychiatric Illness rating system, an empirical model of psychiatric emergency decision-making was constructed and validated on a spilt sample of 254 crisis cases. RESULTS: Three dimensions of the Severity of Psychiatric Illness system-Suicide Potential, Danger to Others, and Severity of Symptoms-were used to construct a model that successfully predicted 73% of decisions about level of care (inpatient or outpatient). Clear misses, patients with a 0.20 probability of being hospitalized who were admitted, and patients with an 0.80 probability or greater of being hospitalized who were not admitted were reviewed to allow for utilization review. This decision support tool then was validated by predicting hospital outcomes in two additional samples. First, a random sample of consecutive admissions to a not-for-profit psychiatric hospital were studied. Second, a panel of admissions from a large managed care firm were evaluated. CONCLUSIONS: Results demonstrate that the decision to hospitalize patients in psychiatric hospitals is rational and that models predicting admission also can predict in-hospital outcomes.

Community Mental Health Centers↗
PubMed1994

How will we use clinical guidelines? The experience of Medicare carriers.

While support for the development of clinical guidelines is widespread, there is little agreement about how they should be used. Because cost control is the force behind the medical effectiveness movement, the payers' preference, to link clinical guidelines to reimbursement, will likely prevail. We examine the utilization review programs of Medicare Part B carriers and the carriers' attempts to use clinical guidelines to determine medical necessity for the purpose of payment. We find that because the utilization review programs are driven by concerns about cost control, the carriers' actual review process relies on aggregate utilization and spending targets that have little to do with clinical guidelines. The carriers' medical review rhetoric--using the terms medically unnecessary and fraud and abuse as synonyms--also highlights their focus on cost control and the lack of concern about why services are used inappropriately.

Attitude of Health Personnel↗
PubMed1996

Charity and community: the role of nonprofit ownership in a managed health care system.

As American medicine has been transformed by the growth of managed care, so too have questions about the appropriate role of nonprofit ownership in the health care system. The standards for community benefit that are increasingly applied to nonprofit hospitals are, at best, only partially relevant to expectations for nonprofit managed care plans. Can we expect nonprofit ownership to substantially affect the behavior of an increasingly competitive managed care industry dealing with insured populations? Drawing from historical interpretations of tax exemption in health care and from the theoretical literature on the implications of ownership for organizational behavior, we identify five forms of community benefit that might be associated with nonprofit forms of managed care. Using data from a national survey of firms providing third-party utilization review services in 1993, we test for ownership-related differences in these five dimensions. Nonprofit utilization review firms generally provide more public goods, such as information dissemination, and are more "community oriented" than proprietary firms, but they are not distinguishable from their for-profit counterparts in addressing the implications of medical quality or the cost of the review process. However, a subgroup of nonprofit review organizations with medical origins are more likely to address quality issues than are either for-profit firms or other nonprofit agencies. Evidence on responses to information asymmetries is mixed but suggests that some ownership related differences exist. The term "charitable" is thus capable of a definition far broader than merely the relief of the poor. While it is true that in the past Congress and the federal courts have conditioned the hospital's charitable status on the level of free or below cost care that it provided for indigents, there is no authority for the conclusion that the determination of "charitable" status was always so limited. Such an inflexible construction fails to recognize the changing economic, social and technological precepts and values of contemporary society. -Circuit Court of Appeals, District of Columbia, Eastern Kentucky Welfare Rights Organization v. Simon (1974).

Charities↗
PubMed1982

Quality measurement and control in physician decision making: state of the art.

The status of the concept of controlling the quality of physicians is reviewed as are studies that have been done on methods to measure and improve quality. The conclusions are dismal given the rhetoric and actions on attempts to measure and control quality of physician decision making. Massive attempts are being made, for example, mandating PSROs to monitor quality before there is a methodology. Cost and quality reviews have, at most, a marginal impact and do not deserve the expenditures to conduct them. Studies on utilization review show minimal impact on reducing utilization. Administrative reviews reduce utilization for certain specific, narrowly defined procedures such as injections. There is no operational definition of "unnecessary" utilization. The tendency is to regard the lowest levels as optimal, presumably because they result in lower expenditures. Bureaucratic reviews do not provide incentives to decision makers the way various types of HMO delivery types do from current evidence. Hence, HMOs, deductibles and coinsurance, and competition have greater promise for limiting expenditures than do utilization reviews. Quality audits are also marginally effective because of limited promise of changing provider behavior given current methods of doing so. They miss the organizational aspects in which incentives are generated. Research is needed, therefore, on alternative forms of quality and cost control such as HMOs, physician risk sharing, competitive models, and deductibles and coinsurance. Until the much needed research has been done, the amount of resources spent on review should be minimized. In the meantime, the review processes should concentrate on extreme variations of very narrowly defined criteria of proven validity while improving the review methodology by systematic research on quality monitoring.

Decision Making↗
PubMed1986

Factors affecting appropriateness of hospital use in Massachusetts.

To determine the extent of inappropriate hospital use, and to investigate factors related to variations in appropriateness, 8,031 hospital records of patients discharged from 41 hospitals in 3 Massachusetts professional standards review organization (PSRO) areas were reviewed in 1973 and 1978. The Appropriateness Evaluation Protocol (AEP) was used for the reviews and logistic regression analysis was used to analyze factors associated with inappropriate use. Based on the results, the authors conclude that utilization review should focus on: longer stays among surgical patients and shorter stays among medical patients; (projected) last third of the stay; and on diagnoses or diagnosis-related groups in which there is less clinical consensus on treatment method. For maximum effectiveness, utilization review must include incentives beyond simple monitoring (e.g., financial incentives).

Data Collection↗
PubMed1989

Health care delivery systems in review.

As physicians grapple with restrictive utilization review procedures, evidence indicates that these measures are not as cost effective as originally believed. Cost containment pressures from employers, limitations on price fixing and incentive arrangements all contribute to a further controlled environment for physicians practicing within HMOs. An SMG census reveals that HMO enrollment grew significantly in 1988, while the number of plans declined. The financial condition of the industry is improving, despite the demise of one of the largest plans. Successful plans are analyzing their market share and developing niche products to improve their position.

Cost Control↗
PubMed1991

Identifying physicians and patterns generating unnecessary in-hospital days. An exploratory stage of developing an institution-specific physician-focused utilization effort.

A focused, concurrent utilization review effort identified the existence of a large number of unnecessary hospital days remaining even after a highly successful utilization review effort. Within a group of physicians identified as having the highest acuteness adjusted average lengths of stay, 38.3% of their patient's hospital days were unnecessary, with 83% of those days being within physician control. Observation, diagnostic undertakings or therapeutic efforts that were unnecessary or appropriate for the outpatient setting represented 81.3% of the unnecessary days. A future utilization study will compare the practice patterns among physicians in the same department in order to define future goals and develop necessary corrective actions that will be acceptable to the medical staff.

Boston↗
PubMed1982

Comparing classification methods: measurement of variations in charges, length of stay, and mortality.

We define and examine three alternative systems for categorizing hospital patients. The first system is based on discharge abstract data alone; the second system is based on discharge abstract data that has been reabstracted from charts for completeness and accuracy; the third system is based on a severity-of-illness index within a diagnostic group. Using acute myocardial infarction patients as an illustrative example, we examine the homogeneity of these categorization systems with respect to charges, length of stay and mortality rates. Our results indicate that a measure of patient severity of illness is essential to produce homogeneous categories to study hospital productivity for utilization review assessment by PSROs, for planning purposes by Health Systems Agencies, for hospital rate setting by cost review commissions and for internal hospital financial management and utilization review studies.

Abstracting and Indexing↗
PubMed2006

Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis.

BACKGROUND: Previous medication management research has focused on hospital and long-term care facility settings, where drug-utilization reviews are used to reduce medication errors. Patients receiving home health care (HHC) are without the benefit of systematic drug-utilization reviews. OBJECTIVE: The purpose of this study was to review medication use in elderly patients receiving HHC to identify the prevalence of potentially inappropriate medication (PIM) use, dangerous drug interactions (DDIs), and other patterns of medication use. METHODS: This retrospective chart review was conducted using data from Medicare recipients aged > or =65 years who were patients of Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Temple, Texas, in 2002. Pharmacists compiled medication profiles based on admissions data. PIM use was identified using the Beers criteria. DDIs were identified using the Multidisciplinary Medication Management Project criteria. Polyphsarmsacy was identified in patients receiving > or =9 medications. RESULTS: Data from 786 patients were included (mean [SD] age, 78 [7] years [range, 65-100 years; median, 78 years]; 36% men; 86% white; and 53% admitted to HHC after a hospital stay). The mean (SD) number of medications was 8.0 (3.7), with 39% of patients receiving polypharmacy. PIM use was identified in 31% of patients. DDIs were identified in 10% of patients, with a significantly higher prevalence in men (P < 0.01). Rates of PIM use and DDIs were 37% and 20%, respectively, in patients receiving polypharmacy. CONCLUSION: In this retrospective data analysis in this population of elderly patients receiving HHC in 2002, PIM and DDI were prevalent, and polypharmacy was associated with increased rates of PIM use and DDIs.

Aged↗
PubMedDate not supplied

Ethical climate in managed care organizations.

Managed care organizations employ nurses as medical utilization reviewers; however, little is known about the ethical climate of these organizations. This study describes different ethical climates in which utilization review nurses work and the implications of these differences for nurse administrators. The nurse participants, although demographically similar across three managed care organizations, perceived distinct ethical climates across the organizations. Nurses were employed to make complex decisions regarding medical care utilization; however, none of the organizations had an ethics committee to help nurse reviewers in this decision-making process. The need for such committees, as well as clarification of a consistent and deliberate ethical climate by nurse administrators, is discussed.

Adult↗
PubMedDate not supplied

Will using evidence-based approaches to a standards development process improve Medicaid policy making? Report on a promising effort.

In theory, evidence-based medical necessity policy in health care utilization review may make resource allocation more equitable. Costs can be managed through the consistent application of standards for approval of only those services deemed medically necessary and by controlling denials and appeals litigation. Additional cost savings may be realized with more efficient utilization review processes and concentration on review standards for the specific items or services that have the greatest financial impact on overall utilization dollars. This article describes a five-step process for evidence-based medical necessity standards development and includes illustrative examples from a state Medicaid agency project. While early results are promising, data are scarce. The authors, nevertheless, believe the approach may prove to be useful on promoting the application of evidence-based decision making.

Benchmarking↗
PubMed1991

Practice guidelines and drug-usage evaluation.

Currently, there is a great deal of interest in the development of practice guidelines for medical care that will be more rigorous and clinically sound than what is available today. With the impetus of federal legislation mandating such an approach, it may continue to develop into a significant movement in the medical arena. Pharmacy managers should be aware of developments in this area, particularly as they relate to appropriateness of drug therapy and drug-utilization review. The result may eventually be an evolution from drug-utilization review programs to diagnosis-based, outcome-focused interdisciplinary systems for QA. Even with the development of practice guidelines as described, there will continue to be a need for competent pharmacy practitioners to ensure appropriate pharmaceutical care. With the increasing acuity of patients in the health care system and the rapid development of new drugs and technologies, the role of the institutional pharmacist in ensuring optimal patient care will be more important than ever.

Clinical Protocols↗
PubMedDate not supplied

Survey addresses quality management issues.

In October 1986, the Academy conducted a survey of its hospital-based members to determine how their institutions organized the staffing of the risk management, quality assurance, and utilization review functions. Academy members David S. Forkosh, MD, FACPE, reports on the results of the survey in this article. (A survey has just been conducted of staffing and staff compensation for quality assurance and utilization review. The results will be reported in an upcoming issue of Physician Executive.)

Data Collection↗
PubMed1994

Healthcare regulation: past, present, and future.

Excessive regulation has created a formidable barrier for physicians to surmount when treating patients. This article examines the increasing intrusion by regulatory agencies--government and private--into the patient-physician relationship. The authors examine the history of healthcare policy leading to today's highly regulated approach to cost-containment. They trace the development of the emphasis on regulatory controls from 1900 to the present. Further, they examine in detail the specific impact of diagnosis-related groups, utilization review firms, and the Clinical Laboratory Improvement Amendments of 1988 on the patient-physician relationship. Diagnosis-related groups set the hospital administration as monitor of the patient-physician relationship. Utilization review firms insert themselves as another gatekeeper in decisions of appropriateness of care. The Clinical Laboratory Improvement Amendments causes laboratories to close, thereby restricting access to care. The reform movement would respect the patient-physician relationship and remove excessive regulation from this confidential interaction. Regulation after reform would react to outcomes rather than controlling the process of healthcare delivery.

Diagnosis-Related Groups↗
PubMed2004

Home health care utilization: a review of the research for social work.

The author reviewed the literature to identify the variables associated with home health care utilization using the Andersen-Newman model as a framework for analysis. Sixty-four studies published between 1985 and 2000 were identified through PUBMED, Sociofile, and PsycINFO databases. Home health care was defined as in-home skilled nursing, homemaker, mobile meals, home health aide, physical therapy, occupational therapy, or social work services. The review indicates that the client most likely to use home health care is elderly, has a high number of ADL/IADL impairments, lives alone, has a low level of informal support, and has Medicaid coverage. In the presence of informal support or when care recipients live with others, the initiation of formal services may be delayed until physical impairment of the care recipient is severe or caregiver burden is high. Implications for social work practice and research are discussed.

Activities of Daily Living↗
PubMed1990

Technology and outpatient review: a preliminary evaluation.

Most health care utilization and cost control programs focus on inpatient care or on high-cost, catastrophic illnesses or injuries. Recently, however, Parkside Health Management Corporation has developed a utilization review program that targets treatments and high-technology procedures performed primarily in an outpatient setting, as well as specific inpatient procedures not included in other review programs. These include chiropractic, podiatric, and physical therapy treatments; cesarean section; and endoscopy, ultrasound in pregnancy, and lithotripsy. The treatments/procedures examined in this program, called Technology and Outpatient Review (TOR), account for approximately 6% of claims expenses. Bigel Institute for Health Policy researchers are evaluating a pilot test to determine TOR's effect on health care costs and utilization, appropriateness, and patient satisfaction.

Ambulatory Care↗
PubMed1998

Inappropriate hospital care and severity of illness: results from a nationwide study.

Little is known about the clinical characteristics of hospital patients who do not meet standard utilization review criteria for acute care settings. This study examined whether patients with either inappropriate hospital admissions or days of care were less severely ill on a number of indicators compared to those designated as appropriate by a widely used utilization review instrument. Using data from a probability sample of 6063 medical and surgical hospitalizations at 50 Department of Veterans Affairs medical centers, we found strong associations between the appropriateness of admissions and days of care and four indicators of severity of illness. These results suggest that utilization management programs and preadmission screening probably successfully screen out less severely ill patients who have less need of hospital-level services.

Adult↗