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PubMed1998

Practice protocols, parameters, pathways, and guidelines: a review.

The evolution of clinical practice protocols is described within the context of its origins in utilization review and utilization management. Physician concerns and barriers to implementation, as well as the role of the Agency for Health Care Policy and Research (AHCPR) are discussed. An example of competing guidelines from the AHCPR and the American Psychiatric Association is described in detail. The available literature on cost savings related to utilization management and clinical guidelines is reviewed and summarized. With over 1,800 medical practice guidelines catalogued, practice protocols have become ubiquitous and continued research into their cost and impact on quality are needed.

Attitude of Health Personnel↗
PubMed1997

Impact of a worker's compensation practice guideline on lumbar spine fusion in Washington State.

OBJECTIVES: In the face of escalating medical costs for injured workers, the Washington State Department of Labor and Industries (L&I), which pays for most workers' compensation costs in the state, established guidelines for elective lumbar fusion as part of its inpatient utilization review program. The guidelines were tied to reimbursement strictures. The authors attempt to assess the effects of these guidelines, which were introduced in November 1988, upon subsequent L&I fusion procedures. METHODS: Discharge data from the Comprehensive Hospital Abstract Reporting System and algorithms using International Classification of Diseases, Version 9, Clinical Modification diagnosis and procedure codes were used to identify lumbar surgical cases. Population estimates were from the 1990 US Census Bureau. RESULTS: During the period of years 1987 through 1992, the lumbar fusion rate for the state showed a 26% decline compared with a 3% decrease for all lumbar operations. After November 1988, when the guidelines went into effect, the state fusion rate declined 33%, whereas rates for nonfusion operations essentially were unchanged. The sharpest decline corresponded in time to implementation of the guidelines. Prior to the initiation of L&I guidelines, the proportion of fusions among L&I patients was higher than among non-L&I patients. The opposite was true by the end of 1992, and the L&I proportion decreased more rapidly than the non-L&I proportion. Time series analysis revealed that both the decline in Washington state lumbar fusion rates and the decline in the proportion of lumbar fusion among L&I patients were statistically significant. CONCLUSIONS: The data suggest that the L&I lumbar fusion surgery criteria and reimbursement standards implemented in 1988 contributed to a decline in rates of performing that procedure. The utilization review aspect of the guidelines as well as the process of involving surgeons in the preparation and dissemination of guidelines also may have been contributory.

Adult↗
PubMed1979

Impact of alcohol, drug abuse and mental health treatment on medical care utilization. A review of the research literature.

This monograph reviews and assesses twenty-five studies that examined the question of whether treatment for mental illness, alcohol abuse or drug abuse reduces subsequent medical care utilization. In general, the studies found that such a reduction did take place. Twelve of thirteen studies found reductions of 5 to 85 per cent in medical care utilization subsequent to a mental health intervention. The median reduction was 20 per cent. The thirteenth study found that mental health services provided in a new neighborhood health center in a medically underserved neighborhood were followed by a 72 per cent increase in medical care encounters. The remaining twelve studies found reductions of 26 to 69 per cent in either medical care utilization or surrogate measures of such utilization subsequent to treatment for alcohol abuse. The median reduction was 40 per cent. The drug abuse literature in this area is sparse and primarily indirect. Although many of the studies suggested that alcohol, drug abuse or mental health (ADM) treatment was a cause of the subsequent reduction in medical care utilization, such causality was not definitively established, due to frequent methodological limitations, such as inadequate comparison groups, short time spans, small samples and lack of trend analysis. In addition, the studies focused primarily on outpatient psychotherapy in organized health care settings, particularly health maintenance organizations (HMOs), and on alcoholism treatment provided through employee-based programs and HMOs. Only very limited policy implications on such topics as health insurance and the linkage of health and ADM services can be drawn from the current body of literature. There is a need for additional research that is broader and more rigorous. To encourage such research, methodological recommendations for future studies are presented.

Alcoholism↗
PubMed1970

Utilization and peer review. Medicine's privilege and responsibility.

Peer review affords a privilege for medicine to participate in the shaping of its future. As a corollary, however, medicine must accept the responsibility of stewardship which attends this privilege. Physicians must be willing to participate even more actively in peer review.Properly, utilization review of professional medical services can be performed only by physicians. They may be assisted by informed lay personnel and by computer-derived data. In no instances, however, should judgment of medical necessity be rendered by computer alone. Although an important function of peer review is the control of health care costs, even more important is the evaluation of the quality of care provided the consumers-our patients."Due process" must be an integral feature of peer review. Any provider must be given the opportunity to discuss his pattern of practice with his peers, and an appellate mechanism must be available.Prospective, rather than retrospective review is preferable, although both approaches are necessary.

California↗
PubMed1976

Critique of an earlier study of the Sacramento Medical Care Foundation's Certified Hospital Admission Program (CHAP).

The Certified Hospital Admission Program (CHAP), which was originated by the Medical Care Foundation of Sacramento, California, is regarded as a prototype of admission certification programs and the concurrent monitoring of inpatient care. These peer review functions have now been made key elements of provider utilization review requirements and of Professional Standards Review Organizations' program operations for Medicare and Medicaid. The present article questions, on methodological and interpretive grounds, earlier published findings and conclusions about CHAP's effectiveness. Significant deficiencies in evaluating its impact may mean that the success of CHAP has not yet been demonstrated and, hence, that an adequate basis for formulating certain national peer review policies may not exist.

Adult↗
PubMed1978

The psychiatrist and health insurance claims review.

Expanded health insurance benefits for the treatment of mental illness have obliged psychiatrists to devote more time to justifying psychiatric treatment to claims reviewers. The author, drawing from experience in utilization review and peer review, summarizes factors contributing to the denial of payment for psychiatric services by health insurers, and gives practical advice on protecting against claims denials and on the process of appealing denials. Psychiatrists should make greater use of peer review committees to justify legitimate treatment services in the face of claims denials. Greater coverage for psychiatric treatment under national health insurance will increase the psychiatrist's responsibility for public accountability. This accountability will require better communication between psychiatrists and claims reviewers.

Insurance Benefits↗
PubMed2000

Effect of geological processes on coal quality and utilization potential: review with examples from western Canada.

This review article compares the elemental and radionuclide concentrations in coals from western Canada, the vast majority of which are used for power generation in Alberta. The coals range in age from lower Cretaceous to middle Eocene, and in rank from subbituminous to high volatile bituminous. Some of the coals were deposited in deltaic lagoonal to marine settings while others formed under lacustrine conditions in intermontane graben settings or in alluvial plains. The role of source rock (provenance), depositional environment, tectonic regime and hydrologic conditions on elemental concentration and distribution will be discussed, with specific examples from western Canada. In addition, the effect of natural weathering, igneous intrusion and self-burning (spontaneous combustion) on the enrichment and/or depletion of elements will be presented. The emphasis throughout this review article will be on the fate of elements of environmental concern and interest (e.g. As, Ba, B, Cl, Co, Cr, Cu, Mn, Mo, Se, Th, U, V and Zn) and of radionuclides of the U and Th series upon coal utilization. This article is also intended for those not familiar with the geological or environmental sciences, particularly as related to fossil fuel utilization.

Alberta↗
PubMed1993

Are psychoanalytic billing practices ethical?

The changing climate of "health care reform" and increased third-party intrusion into psychotherapy are raising challenges over the ethics of traditional psychoanalytic practices such as billing for missed sessions. The practice of billing for missed sessions is an integral part of some analytic psychotherapies and forms the basis of the field of operation of many therapies. When used in this way, the billing practices are unique in medicine in that only these therapies use billing as a part of treatment. This practice is used for a variety of practical reasons but especially to emphasize to patients that the therapy occurs in their internal lives and addresses the symbols they use in organizing their world view. The symbolic use of a time commitment and the obligation to pay for that commitment are necessary so as not to present the patient with a contaminated field of operation. In this way the practice is similar to many other areas of medicine, such as surgeries that are viewed as global procedures whose billing allows for time that is not actually spent in contact with patients. This paper discusses the clinical rationale for the ability to bill for missed sessions and its ethics in terms of the newer language of utilization review. By laying down the principle of billing as a practice parameter for an open-ended bundled service that is billed globally the author translates the practice into more modern utilization-review terminology.

Adult↗
PubMed1995

Psychiatric kibitzing.

Foreword from Dr. Sharfstein: In this era of managed care, utilization review, and concerns about costs, a clinician-reviewer who knows little about a case may make a decision that profoundly affects the course of a patient's treatment. Although Dr. Houghton's timely essay does not involve a managed care or utilization reviewer, it serves to remind us about the dangers inherent in criticizing the work and the judgment of other clinicians.

Adult↗
PubMed1989

Quality and cost-effective management of mental health care.

Corporations have reduced their mental health care benefits by limits on coverage for such services. We report on a comprehensive mental health care program, including prevention and early intervention, hospital utilization review, and consulting psychiatrist, which has improved the quality and has significantly reduced inpatient insurance psychiatric hospitalization costs. Mental health service coverage was actually enhanced. Inpatient psychiatric hospitalization costs 12 months before and after the implementation of a concurrent psychiatric hospital utilization review program were reviewed for a major corporation. Total hospital days and average length of stay decreased by 43% whereas total inpatient psychiatric hospital charges decreased by $309,518. Total inpatient days decreased by 1045. Quality and cost-effective comprehensive psychiatric health care services can be offered by major corporations providing that such benefits are carefully designed and managed.

Chicago↗
PubMed1976

Fugue states in sleep and wakefulness: a psychophysiological study.

A patient's refusal to participate in recommended treatment is a problem faced in all branches of medicine. However, psychiatry faces special problems because of its authority to impose hospitalization and treatment on unwilling patients. Nowhere is this more poignant than in the treatment of patients exhibiting suicidal behavior where the potential for imminent self-destruction exists. As part of a prospective study to develop utilization review standards for the hospitalization of suicide attempters, cases were identified where there was independent agreement between both the experts' standards and the treating resident psychiatrists that hospitalization was required. Despite this agreement, the patients were not hospitalized because the patients refused. By most criteria, these patients were a high risk group. They had made repeated suicide attempts, used lethal means which eventuated in serious medical consequences, and were still suicidal when referred for treatment. The emergency room psychiatrists reported feeling confused, anxious, and annoyed in dealing with these patients, and the patients signed out against medical advice. A review of these cases indicates that discussions of social control vs. medical responsibility and clear criteria for hospitalization should be incorporated into residency training programs since the emergency room resident faces these tension-producing issues frequently with several different types of patients. Moreover, utilization review criteria may help to set standards which will assist the psychiatrist in making these difficult decisions.

Dissociative Disorders↗
PubMed1996

Development of a Comprehensive Surgical Information System at Madigan Army Medical Center.

The Operative Registry (DA Form 4108) has been the information source for surgical data supporting quality assurance and utilization review efforts at Madigan Army Medical Center. Recently, Madigan's requirements for data and reporting changed. Like other government medical facilities, Madigan began pervasive quality-improvement efforts. This resulted in new ideas to measure hospital performance. Consequently, requirements for surgical data required to support quality and resource management reporting, utilization review, residency review reporting, research and credentialing changed. This article details Madigan's approach to addressing these requirements via development of a comprehensive computing solution. It discusses Madigan's fragmented data environment before system development, and gives the reader perspective on the decision-making process that led to system development rather than purchasing a commercial product. Finally, the article describes how a strong partnership between staff and developers was key to providing a solution that exceeded established goals.

Hospitals, Military↗
PubMed1996

Medication prescribing advice and drug utilization: a review from the United Kingdom.

General Medical Practitioners (GPs) in the United Kingdom are usually the first point of contact with the National Health Service (NHS) for patients. They provide the majority of ambulatory care for their practice population and act as 'gatekeepers' for referral onwards to other services. This article investigates the influence of the purchasing authority prescribing advisors (PAs), including pharmacists and GPs on the prescribing habits in Salford, England, an inner city area in the North of England, close to the city of Manchester. The PAs became known as the prescribing CIA, and used the strategy of Control, progressing to Influence and Autonomy, to develop a mature partnership between the GPs, PAs and other health care professionals. Information collated from prescribing (PACT) data, by the Prescription Pricing Authority, was used to make comparisons between different practices within an area. Savings made by making rational changes in prescribing, were used to enhance practice development for the benefit of patient care.

Data Collection↗
PubMed1991

Development of a surgical endoscopy database for quality assurance.

In view of the current incorporation of gastrointestinal endoscopy within surgical residency programs and therefore increased performance of these procedures by surgeons, it is appropriate to devise an effective database which allows retrieval of pertinent information for quality assurance (QA) and utilization review (UR) programs. During the development of two complete surgical endoscopy teaching programs, the QA process has been extensively analyzed for the minimal essential information required to perform QA in compliance with regulations of JCAHO and other reviewing authorities. Over the previous five years this information has been gathered on 3098 patients and incorporated into a database which allows for review of the medical record and the endoscopy unit record for QA and UR. Although the data were entered into a computerized database program for ease of data retrieval and analysis, this information can be complied by the "stubby pencil" method in paper files or log books. The QA process is integrated as part of the general surgery QA, not under a separate endoscopy committee. Results demonstrate that the minimal essential data for the medical record included: patient identification data, endoscopist, procedure, additional procedures, medications, indications, preoperative diagnosis, description of procedure, findings, tissue obtained, complications, final diagnosis, and discharge planning. The endoscopy unit record contained: patient identification, endoscopist, procedure, tissue obtained, and suite complications. From these data elements, complete QA was performed and included: completeness of documentation, appropriate indications, complications, endoscopic versus pathologic diagnosis, and unsuccessful procedures. Utilization review included: number of normal procedures, benefits of screening and surveillance procedures, and appropriateness of preoperative evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)

Databases, Factual↗
PubMedDate not supplied

Health plans' strategies for managing outpatient specialty pharmaceuticals.

Balancing increased spending for specialty pharmaceuticals while providing affordable and equitable coverage for consumers is a key issue for public and private payers. Health plans rely on an array of strategies, including both medical management and those used for more traditional pharmaceuticals. To explore specific management strategies for outpatient specialty pharmaceuticals, a survey was administered to thirty-eight Blue Cross and Blue Shield plans, focused on identifying core strategies. Prior authorization was the most commonly used strategy, implemented by 83.3 percent of respondents. Other frequently implemented management strategies included claims review (82.8 percent), formulary management (76.7 percent), and utilization review (70 percent).

Ambulatory Care↗
PubMed2005

Bench-to-bedside review: antimicrobial utilization strategies aimed at preventing the emergence of bacterial resistance in the intensive care unit.

Antimicrobial resistance has emerged as one of the most important issues complicating the management of critically ill patients with infection. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. The importance of preventing antimicrobial resistance is magnified by the limited availability of new antimicrobial drug classes for the foreseeable future.

Anti-Infective Agents↗