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PubMed1994

Clinical practice guidelines: a review.

The development of clinical practice guidelines has spread from utilization review agencies to physician specialty societies, federal agencies, managed care organizations, and academic health centers as their usefulness in accomplishing the goals of healthcare reform become clear. The author reviews the mounting evidence that variation in the practice of medicine suggests that patients in some areas are not receiving all needed services, while others are receiving unnecessary services. He explores the implications of practice guidelines for improving the quality of care while controlling cost. Practice guidelines are defined and distinguished from medical review criteria. The author explores the challenges in governance, funding, and guideline development and communication that will have to be overcome to establish the credibility of practice guidelines. Finally, he addresses the opportunities for the osteopathic medical profession to establish its uniqueness in this setting.

Education, Medical↗
PubMedDate not supplied

A study of antimicrobial misuse in a university hospital.

We undertook a prospective study to determine patterns and sequelae of antimicrobial misuse and factors associated with inappropriate antimicrobial therapy in a teaching hospital. Over an eight-week period, 144 (26.2%) of 549 hospitalized medical and surgical patients received one or more courses of antimicrobial therapy. An average course comprised 1.4 drugs. Presumptive infection was the reason for 70% of courses and prophylaxis, 30%. Therapy was judged appropriate in 59% of courses overall. Unnecessary therapy, poor drug choice (bacteriologically, pharmacologically, or both), or misguided prophylaxis most frequently underlay inappropriate therapy. Adverse reactions (17% overall) were twice as frequent and the cost of therapy was 55% greater in inappropriate courses. Performance of pretherapy cultures (p less than 0.05), obtaining gram-stained smears of sputum in presumed respiratory tract infections (p 0.001), and notation in the record that antimicrobial therapy had been instituted (p less than 0.001) were strongly associated with appropriate therapy. This study underscores the need for more effective programs of postgraduate education which stress basic principals of infectious disease and antimicrobial pharmacology and guidelines for prophylaxis. Antimicrobial utilization review should figure heavily in hospital programs of medical self-evaluation. Additional measures to upgrade the use of antibiotics are discussed.

Anti-Bacterial Agents↗
PubMed2000

Understanding and managing integrated delivery networks.

This article presents a guide for "managing managed care." To be successful in the transition from the fee-for-service payment system to capitation, the manager first needs to understand the five roles (the players), and their integration. The five roles are the employer, the insurer, the primary care physician, the specialist physician, and the hospital. Once a health care manager understands the dynamics between these roles and their involvement in operations such as finance, contracting, and utilization review, managed care can then be managed. This guide is also beneficial to managers for understanding how to work with someone in another role.

Delivery of Health Care, Integrated↗
PubMed1997

New team system speeds billing time.

PROBLEM: Fragmented, departmental approach to billing at UCLA Medical Center in Los Angeles had bills bogged down in a bureaucratic maze. SOLUTION: Patient administrative service teams based in nursing units combine functions of admissions, registration, utilization review, medical records, and patient accounting to cut billing cycle from 30 days to 12.

Admitting Department, Hospital↗
PubMed1985

DRG clinical surveillance: an approach to internal control.

In the present healthcare environment, internal control of hospital resources is becoming increasingly important. One hospital's approach to instituting internal control is the development of a DRG clinical surveillance program. This program uses utilization review in conjunction with quality assurance to provide the hospital with a working framework for determining whether hospital admission is appropriate or whether an alternative method of healthcare delivery should be used.

Concurrent Review↗
PubMedDate not supplied

The appropriateness of admissions and the influences on a decision to admit.

Within health services there is concern that escalating costs may reflect an inappropriate use of services and that services should avoid admitting patients who do not require acute care. The problem is, if these patients exist, how may they be identified and is this the sole consideration in patient management? This triangulated study examines the appropriateness of admissions, factors that influence that admission, and the potential to develop alternate models of care for medical patients. A utilization review, auditing 521 medical patients, provided a percentage of appropriateness of admission and stay, identified the barriers to discharge and those patients suitable for programs such as hospital in the home. Complementing the review, interviews with eight physicians explored how they decided to admit patients, what factors influenced that decision and their attitude to the development of these models of care.

Decision Making↗
PubMed1981

The development of dental practice profiles.

This study examines the amount and sources of variation in dental practice profiles. Three years of insurance claims data on 227 general dental practices were used to generate practice-specific utilization rates for 16 treatment service categories. The results indicated considerable heterogeneity among and within practices in the distribution of service utilization rates such that most distributions could not be described by conventional parametric probability models. Basic standardization methods were used to examine sources of variation among practices. Of the patient and insurance characteristics investigated, only patient age had a major effect on utilization rates. However, there was considerable stability in utilization rates within practices over four consecutive six-month time intervals. The implications of these findings for profile-based utilization review and quality-assurance systems are discussed.

Adolescent↗
PubMed1992

Regulating managed care firms: the Connecticut plan.

Virtually every state in the country, as well as the federal government, is either considering or has recently considered legislation to regulate utilization review/managed care companies. Despite the magnitude of this issue, few legislative bodies have expended the resources to study the form that regulation should take. Recently, Connecticut, which has seen considerable growth in utilization review within managed care programs that insure Connecticut residents, funded such a study. This article, authored by two of the study's participants, reviews the issues and explains the study's recommendations.

Attitude of Health Personnel↗
PubMed1987

Software for health care analysts: a modular approach.

The many concerns about the cost and quality of health care suggest the need to facilitate planners' using existing data bases for utilization review, program evaluation, and technology assessment. Despite both the availability of relevant data and widespread improvements in computing power, integrated computer software to permit analyses by nonspecialists has not previously been developed. This paper discusses the features of a health policy information system which aids working with hospital discharge abstracts, medical claims, cancer registries, and vital statistics files. Analyses of small area utilization, length of stay, in-hospital mortality, and readmissions are facilitated by this package. This information system, named the Health Applications System, includes an analysis module, three information management modules, and a set of record linkage modules. The modules were developed using the macroprocessor in the fourth-generation SAS system. Features of the software and their implications for data analysis are discussed.

Data Interpretation, Statistical↗
PubMedDate not supplied

QA, RM and UM functions require coordinated information management.

The public demand for access to health care data in general has created a flurry of activity at the health care provider level. Specifically, data on quality plays a pivotal role in this competitive, litigious and cost-conscious environment. Currently, data (manual or computerized) on clinical and organizational performance is sparse, although health care institutions have traditionally had QA and related utilization review, risk management and peer review activities in place to fulfill requirements for licensing and accreditation. Where data exists in isolated pockets, little coordination or integration has occurred, thereby diminishing the potential value of the data as part of a comprehensive information system. Today, institutions are responding to the demands for QA, RM, UR data in many ways. Much progress has been made in establishing comprehensive QA programs utilizing centralized, coordinated data from multiple sources to demonstrate both clinical and organizational performance. These comprehensive programs have clearly defined the need for computerization with the ability to re-use existing information. Applying this technology, however, requires assessment and planning. Allowing department-oriented, microcomputer-based application prevents sharing of resources and in many cases results in redundant and perhaps uncoordinated data capture. Decentralizing of the decision-making process leaves the ultimate selection of computerized QA and related applications to the individual user, whose focus is generally centered on his/her own priority. These systems are frequently incompatible with other existing systems. This approach will not support the institution's need to provide timely, accurate, complete information about the quality of service rendered nor information critical for internal management and planning.(ABSTRACT TRUNCATED AT 250 WORDS)

Centralized Hospital Services↗
PubMed1996

Formulary: what it is and how it works.

Estimates for healthcare expenditures in 1993 exceeded $900 billion, approaching 15% of GNP. Of this, approximately 7.5% ($62 billion) was spent on drugs. More recently, costs show that the US spends over $3,000 per person per year on healthcare. Although no one disputes that the cost of healthcare is rising, generally the rate at which it rises is not as rapid in a managed care environment compared to a fee-for-service one. Because of this, the boundaries of managed care and pharmacy benefits management (PBM) continue to expand. Outpatient drug benefits, for instance, are being carved out of the medical benefit offered by several types of insurance programs. This is mainly a result of point-of-sale claims processing and enhanced information system data base reporting making the drug portion easier to identify and separate from other medical claims. Self-funded employers are now actively seeking PBM companies to contract with for this type of service. The services being offered by PBM companies include: Pharmacy networks in which plan members fill prescriptions at a discounted or contracted rates. Disease state management. Drug utilization review. Financial reporting. Formulary management. The main component of formulary management is the development and distribution of a drug formulary. This article discusses what a drug formulary is and how it works.

Cost-Benefit Analysis↗
PubMed1997

Drug education. Moving ahead the fourth year.

The Omnibus Budget Reconciliation Act (OBRA) of 1990 required all states to implement drug utilization review programs for outpatient medications covered by Medical Assistance. This second of a two-part series outlining the activities of the State Society's Center for Professional Drug Education and Information discusses the effectiveness of Pennsylvania's program.

Drug Utilization Review↗
PubMedDate not supplied

Effect of practitioner education on adherence to asthma treatment guidelines.

OBJECTIVE: To determine whether a letter-based intervention program submitted to prescribers and pharmacists would improve drug therapy in users of high-dose beta(2)-agonists (HDBs). STUDY DESIGN: Retrospective drug utilization review. PATIENTS AND METHODS: The intervention group consisted of 135 asthmatic patients (identified through ICD-9-CM codes) in the Connecticut Medicaid Program who submitted >1 claim per month for short-acting beta(2)-agonists (over a 6-mo period). Patient-specific intervention packets were mailed to the patients' prescribers and pharmacists, and their use of long-term control agents and healthcare utilization was evaluated over 6 months. These variables were compared with a comparison group (n = 510) of asthmatics drawn from the same Medicaid program who were not considered to be high-dose users of short-acting beta(2)-agonists at baseline. RESULTS: Prior to the intervention, the intervention group used fewer long-term asthma control agents as compared with the comparison group (58% vs. 96%; p < 0.001); there was no significant difference after the intervention program (65% vs. 71%; p = 0.169). The acquisition of spacers was greater in the intervention group than in the control group after the intervention (7% vs. 2%; p = 0.007). At the end of the 6-month intervention period, 46% of patients in the intervention group were no longer HDB users (p < 0.001). The higher frequency of prescriber office visits in the intervention group than the comparison group before the intervention (0.46 +/- 0.82 vs. 0.25 +/- 0.66; p < 0.001) was not evident after the intervention program (0.24 +/- 0.63 vs. 0.18 +/- 0.60; p = 0.283). CONCLUSIONS: This intervention program had modest impact on improving the use of long-term control agents and reducing prescriber office visits.

Adrenergic beta-2 Receptor Agonists↗
PubMed1983

Identification of practice problems in dentistry.

This paper examines the use of dental insurance claim data for studying the dental care delivery system. Several research projects are described including investigations of the amount, types and causes of variation in dental practice patterns, the cost-effectiveness of different patterns of care in producing oral health, the feasibility of focused utilization review systems and the selection of continuing education topics and participants. The importance of these and other data information systems to the future practice of dentistry and medicine is stressed.

Dentistry↗
PubMed1985

Physician reimbursement for services to HMO-sponsored patients. An academic model.

When the University of California, San Diego (UCSD) School of Medicine faculty and UCSD Medical Center became participants in a capitated health care program, it became necessary to reevaluate the method of reimbursement for physicians' services. In developing a new formula, the faculty established specific objectives for the program and agreed to a plan that was not fixed to predetermined unit value for physicians' services but rather was a function of residual capitated income after program expenses. The formula prescribed that 50% of capitation income available for physicians' reimbursement would go to primary care physicians who were paid based on the number of patients in their panels and 50% to specialty physicians based on their clinical activity. This scheme and an aggressive utilization review process were associated with a rate of hospitalization and physicians' reimbursement that met or exceeded anticipated results during the first 2 years of operation.

Academic Medical Centers↗
PubMedDate not supplied

Computers in case management. Advancing health care delivery through technology.

Fast efficient access to patient information is an essential management tool in the current healthcare environment. The clinical case management computer module at Stanford Health Services provides and integrates essential patient data elements to facilitate clinical case coordination and assist the nurse case managers with documentation of clinical data for discharge planning and utilization review. Information systems such as this one are critical to the provision of comprehensive, cost-effective patient care management.

Case Management↗
PubMed1993

Pennsylvania takes lead in drug education venture.

The Omnibus Budget Reconciliation Act (OBRA) of 1990 required all states to implement drug utilization review programs for outpatient medications covered by Medical Assistance. The State Society is taking a lead role in its response to the retrospective portion of the program. This article explains that role and overviews how OBRA requirements will affect Pennsylvania physicians.

Drug Utilization Review↗