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PubMed1999

Hospital brings social work into case management fold.

To prepare for a wave of managed care penetration and to reduce duplication of work, 240-bed Jefferson Memorial Hospital in Crystal City, MO, integrated its social work and utilization review departments. The resulting case management services department features seven case coordinators and three social workers who often work out individual responsibilities for a given case among themselves. The newly hired case coordinators received extensive training in utilization review and discharge planning. The training curriculum involved trips to home health, hospice, a rehabilitation hospital, and a larger case management department.

Case Management↗
PubMed1984

Identification of drug costs within diagnosis related groups.

This study was designed to identify the DRG distribution of discharged Medicare patients during a given period of time in two similar hospital sites. Additionally, drugs costs (both total and average) for each patient in these DRGs were determined and analyzed as to similarity between the two sites as well as significance in terms of percentage of DRG total reimbursement rate. The assumption that DRGs would be homogeneous for drug costs was not found to be true in this study. Percentage of total reimbursement attributed to drug costs for DRG categories studied (less than 4%) was consistent with previously acquired data in established DRG prospective payment programs. Average drug cost was not found to be a reliable indicator for comparison of drug utilization, either within DRGs or between hospital sites. Length of stay emerges as the primary focus for future efforts in drug utilization reviews and cost control programs. A model for future DRG-based drug utilization reviews is proposed.

Analysis of Variance↗
PubMed1987

Medicare risk contracting. Lessons from an unsuccessful demonstration.

The Tax Equity and Fiscal Responsibility Act of 1982 provided a full-risk Medicare capitation financing option for health maintenance organizations and competitive medical plans. Two rounds of demonstrations were conducted, followed by the publication of final regulations in January 1985. The first-round demonstration at Marshfield, Wis, was operational for 28 months. Thirty-seven percent of all resident beneficiaries enrolled. Aggregate losses exceeded $3 million (11.6% of revenue). Management implemented increasingly more stringent utilization review. Overall hospital utilization declined 261.7 days per 1000 from fiscal year 1981 to 1982; nonetheless, federal reimbursement was insufficient to meet program costs and the demonstration was terminated. The central reimbursement method used in Medicare risk contracting (adjusted average per capita cost) does not adequately control for enrollment selection, unmet medical need, or recent regional cost variations. Reimbursement set at 95% of estimated fee-for-service costs does not recognize, and in the long run will not support, an efficiently operating delivery system.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

Management of hypercholesterolemia: practice patterns for primary care providers and cardiologists.

This retrospective study, conducted as part of a private practice quality assurance process for patients with coronary artery disease (CAD), compares practice patterns in the LIFEHELP lipid clinic and non-lipid clinic settings at the Heart Institute of St. Petersburg. Quality assurance parameters included documentation of low-density lipoprotein (LDL) cholesterol, initiation of lipid-lowering therapy, and achievement of the Second National Cholesterol Education Program (NCEP II) goal for CAD patients of LDL cholesterol < or =100 mg/dL. A total of 934 patient charts with ICD-9 codes of 410-414 for ischemic heart disease were randomly selected and reviewed by a utilization review nurse. A higher level of documentation and treatment of elevated LDL cholesterol to NCEP II goal in CAD patients was found for those followed in the lipid clinic. Among non-lipid clinic physicians, cardiologists documented and treated elevated LDL cholesterol more frequently than primary care physicians. Women and the elderly subgroups received improved care in the lipid clinic setting. Screening activities and risk-factor management by cardiologists within a lipid clinic, therefore, demonstrated an improved standard of care that came closer to achieving national guidelines in the secondary prevention of CAD.

Age Factors↗
PubMed1999

Integration trend gains steam: how to avoid pitfalls when disciplines merge.

If your hospital hasn't already collapsed social work, utilization review, discharge planning, and other disciplines into case management, it's probably just a matter of time before it does, experts say. And whether or not the integration effort succeeds depends largely on the real motivation behind it. Simply mashing case management and utilization review together in an effort to cut costs--and corners--is likely to result in tension among all disciplines involved and may not be in the best interests of patients. At University Hospital in Denver, the case management team has partnered with the Office of Clinical Practice to form a unit that preserves the integrity of both case managers and quality managers while giving each group a better perspective on how their roles interrelate.

Case Management↗
PubMed2002

Clinicians as advocates: an exploratory study of responses to managed care by mental health professionals.

Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed that experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that managed care plans retaliate against advocacy behavior appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.

Behavioral Medicine↗
PubMed1998

Slow pay and claims denials: welcome to the world of managed care.

In markets heavily penetrated by managed care, case managers are facing a disturbing trend: Health plans are denying claims at an alarming rate for what many consider to be medically necessary care. Slow payment and increased scrutiny of hospital utilization review also have been reported. In Maryland alone, the state's largest insurer, Blue Cross and Blue Shield, denied $29 million in hospital claims and 13% of all inpatient days in 1997, leading the state hospital association to file a grievance alleging that BCBS and other insurers are denying claims simply to cut costs. Experts argue that the trend toward claims denials and slow payment is likely to increase the administrative burden of case managers who perform utilization review, and could negatively affect patient care.

California↗
PubMed1991

Managed care: practice, pitfalls, and potential.

The results of coordinating and changing patterns of health care using managed care activities and organizations are reviewed in this article. Although utilization review and high-cost case management programs reduce the use of expensive services, incentives for providers of care, placing them at risk, are important for managing the intensity of health care. Managed care appears capable of reducing health care costs substantially. However, this increased efficiency has not translated to lower insurance premiums or modulated total health care expenditures because either purchasers are not aware or are not concerned about securing care at the least cost. To correct these deficiencies and deliver the potential of managed care, the author suggests the need to separate insurance into its three components parts (financing, risk spreading, and program management) and developed policies for each.

Cost Control↗
PubMed1991

Focused psychiatric review: impacts on expense and utilization.

Focused Psychiatric Review, Aetna's inpatient mental health utilization review program, reduces length of stay and stabilizes admission rates and, as a consequence, reduces expenses, according to the study reported in this article. The program has greater impact on psychiatric than on substance abuse treatments. The best estimate of annual net program savings is $34.90 per covered employee, a return of $12.60 saved for each program dollar spent.

Data Collection↗
PubMed2006

A senior care clerkship for pharmacy students.

OBJECTIVE: This paper describes a 200-hour senior care clerkship for pharmacy students over a five-year period from 1998-2003. SETTINGS: This clerkship used community long-term resources of a 160+ bed skilled nursing facility, adult day care, and senior citizen centers involving medicine, pharmacy, and nursing preceptors. PRACTICE DESCRIPTION: The facility consultant pharmacist was the primary preceptor of students. He conducted pharmacy rounds and daily patient case reviews three times per week. He provided monthly drug regimen review (DRR) and quarterly drug utilization review (DUR) to the skilled nursing facility and, as needed, consultation and therapeutic recommendations to the adult day care center and the senior citizen center. PRACTICE INNOVATION: A 200-hour clerkship was developed with multidisciplinary preceptor experiences to orient internal and external PharmD students to long-term care adult consultation with the attending physicians and nurses in the three sites. Each student prepared for physician rounds by performing an intensive DRR process for selected nursing facility patients. This included a preliminary discussion with the charge nurse on the unit and the consultant pharmacist. As directed, each rotation group proposed and completed one DUR project and written report. The overall goal was to enable the student to serve as a consultant pharmacist and, upon graduation, become a certified geriatric pharmacist. Rotation-specific objectives, evaluation instruments, and DRR and DUR processes are described. MAIN OUTCOME MEASUREMENTS: Documentation of contact time, completion of DRR and DUR activities, and interprofessional communication activities. RESULTS: There were 96 students who completed a 200-hour clerkship over five, 40-hour weeks during a five-year period from 1998 to 2003. Students evaluated some 10,000 patient-months of skilled nursing facility drug therapy and completed 20 DUR projects. All former students who have provided verbal feedback on their clinical training in this rotation have indicated that the rounds and conference contact with the medical director and med passes with the nurse were the key components in that they contributed most to effective interprofessional communication beyond what the consultant pharmacist preceptor offered. CONCLUSIONS: A senior care clerkship can be enhanced with medical director preceptorship in conjunction with the facility consultant pharmacist and nursing staff. This clerkship offered an experiential training that enabled pharmacy students to more effectively communicate with attending physicians and nurses, provide senior pharmacy care, and orient students to the opportunity for geriatric pharmacist certification.

Aged↗
PubMed1987

Computerized data bases: an integrated approach to monitoring quality of patient care.

Common information is shared by rehabilitation program evaluation, utilization review, and quality assurance. These administrative functions sometimes operate in isolation, not taking advantage of information sharing. This approach fails to recognize the potential for increased efficiency of integrating pertinent information to produce timely and useful reports. We report on a system design which addresses this concern by encouraging information sharing, reducing data duplication and creating a data base to produce needed statistical and management reports. Our discussion highlights the key elements of program evaluation, utilization review, and quality assurance. These elements are described as an integrated approach to meet the Commission on Accreditation of Rehabilitation Facilities and revised Joint Commission on Accreditation of Hospitals standards.

Database Management Systems↗
PubMed1987

Effect of an educational intervention on oral cephalosporin use in primary care.

The prescribing of oral cephalosporin antibiotics in an ambulatory setting was evaluated before and after an educational intervention. A drug utilization review used previously developed criteria to study the indications, processes, complications, and outcome for oral cephalosporins in the outpatient setting. Baseline data were collected for one year in the initial phase of the study. Only one prescription (1.4%) in the initial phase (0.96% of the total) met the criteria for appropriate use. However, during the year after an educational intervention by a clinical pharmacist explaining the proper use of oral cephalosporins, the prescribing of these agents decreased substantially. Educational strategies in medical schools and residency programs that seek to improve drug-prescribing behavior should combine drug utilization review programs with specific education about the appropriate use of pharmacologic agents.

Administration, Oral↗
PubMed1995

An overview of Spanish studies on appropriateness of hospital use.

This paper is an overview of hospital utilization review in Spain. Most of the hospital utilization studies have used the Appropriateness Evaluation Protocol as the review instrument. The studies, mainly retrospective, started in the late 1980s and used different adaptations of the medical-surgical version of the protocol. The level of inappropriate use detected ranges between 2.1 and 44.8% for admissions, and from 15 to 43.9% for inappropriate days of stay. The variability in the detected degree of inappropriateness may be due to the differences in the review instrument, the use of the override option, the patients included in the study, or the setting. The determinants of inappropriate hospitalization in Spain are mainly related to access to the different levels of care and to the conservative attitude of the physicians. Future utilization review in Spain should be followed by the development of specific interventions to correct the current pattern of overutilization.

Bias↗
PubMed1996

Phase II of the AHCPR-sponsored heart failure guideline: translating practice recommendations into review criteria.

BACKGROUND: In 1992, under the sponsorship of the U.S. Agency for Health Care Policy and Research, RAND assembled an expert panel to develop the Heart Failure Clinical Practice Guideline. Phase II of the effort was intended to identify which of the guideline's recommendations the panel felt were suitable for use in retrospective utilization review and quality assessment programs and to develop review criteria, performance measures, and standards of quality for use in monitoring compliance with those recommendations. SELECTION OF RECOMMENDATIONS: Selecting guideline recommendations for translation into review criteria and ultimately into standards of care was a multistep process comprising (1) identification of 34 recommendations from the guideline, (2) rating them on the basis of importance to quality of care and feasibility of monitoring, (3) review by a subcommittee and the full guideline panel, (4) translation into review criteria, and (5) further review and input by panelists and peer and pilot reviewers. Finally, standards of care (the minimum proportion of cases expected to be in accordance with guideline recommendations) were determined to be 90%-95% for six of the final criteria and 75%-80% for the other two. CONCLUSION: Despite some reservations, physicians and other health care professionals agreed to be held accountable for following a core set of guideline recommendations for the treatment of heart failure. Substantial progress was made in identifying recommendations that panelists and reviewers were willing to endorse in utilization review activities, including adoption of improved documentation standards. The review criteria's major impact may be the knowledge that the criteria are in place and that care is being monitored based on those standards.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2002

Use of inappropriate prescription drugs by older people.

OBJECTIVES: To determine the prevalence and predictors of inappropriate drug prescribing defined by expert national consensus panel drug utilization review criteria for community-dwelling older people. DESIGN: Survey. SETTING: Five adjacent urban and rural counties in the Piedmont area of North Carolina. PARTICIPANTS: A stratified random sample of participants from the fourth (n = 3,234) and seventh (n = 2,508) waves of the Duke Established Populations for Epidemiological Studies of the Elderly. MEASUREMENTS: The prescribing appropriateness for digoxin, calcium channel blockers, angiotensin-converting enzyme inhibitors, histamine(2) receptor antagonists, nonsteroidal antiinflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and antidepressants as determined by explicit criteria (through Health Care Financing Administration expert consensus panel drug utilization review criteria for dosage, duplication, drug-drug interactions and duration, and U.S. and Canadian expert consensus panel criteria for drug-disease interactions). Multivariable analyses, using weighted data adjusted for sampling design, were conducted to assess the association between inappropriate prescribing and demographic, health-status, and access-to-healthcare factors cross-sectionally and longitudinally. RESULTS: We found that 21.0 of the fourth wave and 19.2 of the seventh wave participants who used one or more agents from the eight drug classes had one or more elements identified as inappropriate. The therapeutic classes with the most problems were benzodiazepines and NSAIDs. The most common problems were with drug-disease interactions and duration of use. Longitudinal multivariable analyses found that participants who were white (adjusted odds ratio (AOR) = 1.67, 95 confidence interval (CI) = 1.28-2.17), were married (AOR = 1.40, 95% CI = 1.01-1.93), had arthritis (AOR = 1.74, 95% CI = 1.27-2.38), had one or more physical function disabilities (AOR = 1.42, 95% CI = 1.02-1.96), and had inappropriate drugs prescribed at wave 4 (AOR = 6.87, 95% CI = 5.11-9.22) were more likely to have inappropriate prescribing at wave 7. CONCLUSION: These results indicate that inappropriate prescribing is common among community-dwelling older people and persists over time. Longitudinal studies in older people are needed to examine the impact of inappropriate drug prescribing on health-related outcomes.

Aged↗
PubMedDate not supplied

Severity adjustment for length of stay: is it always necessary?

OBJECTIVE: Severity adjustment is an oft-cited requirement when comparing physicians or medical delivery systems. Each application of severity adjustment, however, has to be tested to validate the need, the method, and its value. We examined the value of severity adjustment for identifying physician outliers when studying length of stay in the hospital. DESIGN: We compared the placement of physicians in an outlier category using a severity-adjusted average length of stay (SLOS) index with their placement using the unadjusted average length of stay (ALOS). Changes in placement of the list were validated by the utilization review coordinators. SETTING: A 614-bed tertiary-care university teaching hospital. SUBJECTS: We analyzed 11,146 discharges from 138 physicians in 1992. RESULTS: The mean ALOS +/- standard deviation was 9.05 + 4.50 days, and the SLOS Index was 7.56 +/- 3.06. There were 120 inliers, 6 high outliers, and 12 low outliers by the ALOS method. Using the SLOS index, 27 of 138 physicians had their categories changed from inlier to outlier or from outlier to inlier. The difference in group changes was more significant for those going from outlier to inlier status (8/120 vs 6/18; P < .001). The patients of the six physicians whose status changed from outlier to inlier status were sicker, as indicated by the comorbidity, complications, and manifestations of disease processes score. The utilization reviewers validated the status changes in 8 of 14 instances. CONCLUSIONS: Severity-adjusted length of stay by the SLOS index appears to provide a more accurate measure than the unadjusted ALOS. The changes, however, were small. It is not clear that the added effort is worthwhile.

Hospital Bed Capacity, 500 and over↗
PubMed1986

Evaluating the impact of education by a clinical pharmacist on antibiotic prescribing and administration in an acute care state psychiatric hospital.

An antibiotic utilization review program was implemented by a clinical pharmacist in an acute care state psychiatric facility. Antibiotic utilization was concurrently audited in 61 antibiotic orders, written for 48 patients, in order to determine antibiotic prescribing and administration practices and problems. Interventions, consisting of educational presentations, problem-solving meetings, and distribution of written educational materials, were provided by a clinical pharmacist to improve antibiotic prescribing and administration practices. A second audit of 68 antibiotic orders written for 47 patients was concurrently audited after completion of the interventions. When prescribing problems were detected, the clinical pharmacist made recommendations to the prescribing physician. Statistically significant changes in the use of culture and sensitivity tests, appropriate dosage regimens, correct antibiotic administration, and selection of cost-effective therapy were found after all educational interventions were provided. A positive trend not resulting in statistical significance was noted for documentation of infectious disease and selection of appropriate antibiotic agents. This study demonstrates a drug utilization review role for clinical pharmacist's involvement in the acute care psychiatric facility, and illustrates one method by which clinical pharmacists can provide educational programs to improve nonpsychotropic drug prescribing and administration in this setting.

Adolescent↗