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This is the eighth article in a multi-part software reference guide series which began in the September 1986 issue of JAMRA. The focus of this month's article is software for utilization review. Like all articles in the series, this one is intended to assist medical record professionals as they seek ways to enhance the efficiency and effectiveness of the medical record services they provide.
The relational database is especially well suited to be the cornerstone of the next generation of health care information systems. Health care organizations can take advantage of the lessons learned from major corporations that have built entire information infrastructures using it. The relational model's strength in handling the analysis of transaction data makes it ideal for fulfilling complex utilization review requirements and providing a solid foundation for the increasing operational demands of large physician-managed managed care networks.
This final rule revises some of the regulatory requirements for the drug use review (DUR) program for covered outpatient drugs furnished to recipients under the Medicaid program. The regulatory requirements became effective on January 2, 1993, as a result of an interim final rule with comment period that we published on November 2, 1992. Specifically, these revisions-- Clarify the definitions of overutilization, underutilization, consensus process, peer-reviewed literature, adverse medical result, adverse drug-drug interaction, appropriate and medically necessary, and individual medical history; Change the requirements for licensure of DUR board members, and telephone counseling arrangements for mail order pharmacies; Include non-prescription drugs in the consideration of alteration of therapeutic effect; Require hospitals to give assurances that they have met the requirements of the statute before claiming the hospital exemption from DUR; Specify the issues that State agencies must address when formulating counseling standards; Clarify the bases for DUR board recommendations; Clarify the distinction between DUR and surveillance and utilization review (SUR); and Make certain technical and editorial corrections. The November 1992 interim final rule with comment period incorporated and interpreted certain provisions of section 4401 of the Omnibus Budget Reconciliation Act of 1990.
The results of an evaluation of a predischarge utilization review program [PDUR] for Medicaid Patients are presented. A group of hospitals in Allegheny County, Pennsylvania, participated in this program on a voluntary basis prior to the program's being mandated statewide. All other hospitals in the county experienced retrospective review of Medicaid cases. Our analysis incorporates both types of hospitals in a quasi-experimental design. We found that during the period studied the length of stay of Medicaid patients fell proportionately more than that of the Blue Cross patients in both groups of hospitals; the relative decrease in the length of stay began to occur prior to the introduction of the PDUR program, but no differential effect of the PDUR review process could be demonstrated. The decline in the length of stay was, however, more continuous and smooth in those hospitals participating in the program.
The 1995 Republican House Medicare reform proposal introduced the provider services network (PSN) concept as a new healthcare delivery model for accepting and administering Medicare risk contracts. A PSN operates much like an HMO, but is not subject to the reserve requirements established for HMOs. Providers that want to enter the Medicare risk contracting arena and exercise more control over the delivery of healthcare services may consider forming a PSN. To form a PSN, providers must be sufficiently capitalized to compete with HMOs, create a formal legal organization, and develop a financial plan. To ensure that its goals are met, the PSN must develop a sales promotion plan, enroll members, control and monitor financial resources and clinical outcomes, and implement a management information system. Other crucial capabilities that a PSN must develop include establishing mechanisms for utilization review, membership information maintenance, claims adjudication, physician credentialing, quality assurance, and member grievance procedures.
OBJECTIVES: To assess the effect of a comprehensive, educational antibiotic management program designed to improve antibiotic use and reduce treatment costs in elderly patients with suspected urinary or respiratory tract infection. DESIGN: Interventional cohort study with 12 cross-sectional drug utilization reviews of antibiotic use before, during, and after the multifaceted intervention. SETTING: A 304-bed university hospital for geriatric patients. PARTICIPANTS: A total of 3,383 elderly patients. INTERVENTIONS: An educational program including distribution of guidelines on the diagnosis and treatment of urinary and respiratory tract infections; lectures on geriatric infectious diseases; weekly ward rounds for patients with suspected infection; and targeted, individual counseling on diagnosis and antibiotic treatment of infections. MEASUREMENTS: Antibiotic utilization data were collected from the patients' records. Antimicrobial costs were calculated using 1998 hospital wholesale prices. RESULTS: Of 3,383 screened patients, 680 (20%) received at least one antibiotic. During the study period, the mean number of prescribed drugs per patient increased from 5.9 to 7.6 (29%; P<.001). In contrast, a reduction of 15% was observed in the proportion of patients exposed to antibiotic agents (P=.08) and a drop of 26% in the number of antibiotics administered (P<.001). This resulted in a 54% decrease in cumulative daily antibiotic costs. In 83 (75%) of 110 surveyed patients, the guidelines were correctly implemented. The intervention had no measurable negative clinical effect. CONCLUSION: A comprehensive, multifaceted educational program for treating urinary and respiratory tract infections in the elderly was a safe and practical method to change physicians' antibiotic prescribing practice and significantly reduce the consumption and costs of antibiotics in a geriatric hospital.
OBJECTIVE: To investigate primary care physicians' recognition and evaluation of red blood cell (RBC) macrocytosis in adults. DESIGN: Retrospective chart review. Utilizing a computerized laboratory result system, all complete blood counts (CBCs) with RBC indices performed between May 1986 and May 1987 were retrieved. Patients having mean corpuscular volumes (MCVs) more than three standard deviations from the mean (greater than 98.5 fL) were selected for evaluation. SETTING: The primary care clinics of a public university hospital. PATIENTS: 138 (3.7%) of 3,805 adult outpatients had MCVs greater than 98.5 fL, and of these, 128 (93.4%) had medical charts available for review. RESULTS: 55 patients with elevated MCVs were not evaluated for this finding, and their mean MCV (100.6 fL) was significantly lower than that of the 73 patients who were evaluated (102.5 fL; p = 0.003). The investigation of macrocytosis included vitamin B12 and folate levels consistently, and the reticulocyte count and peripheral smear were examined infrequently. Five patients had vitamin B12 deficiency, and two had hypothyroidism. Macrocytosis was ascribed to alcohol abuse in 47 patients, six of whom had no laboratory evaluation. Nine alcoholic patients with macrocytosis had other causes for this finding. Among the 55 patients whose macrocytosis was not evaluated, 12 were anemic and one had a peripheral neuropathy. CONCLUSIONS: Clinically significant and treatable disease was often associated with macrocytosis in our study. Macrocytosis was common, and its recognition and evaluation were variable in this primary care outpatient setting.
The internal quality assessment and assurance activities in U.S. hospitals can be described in terms of four specific programs: quality assurance, utilization review, risk management, and patient/guest relations. Quality assurance also depends on a strict control of licensing for the health professions, with state and federal involvement, and on a robust malpractice complaint system.
This paper describes a study of drug use and drug-related problems in community-dwelling elderly (> or =65 years) Medicaid recipients in Maryland, Iowa, and Washington from 1989 through 1996. A claim-by-claim review of Medicaid prescriptions was conducted to detect 5 types of prescribing problems (dose, duration of therapy, duplicative therapy, drug-drug interactions, and contraindications or initial therapy). The study examined 8 drug categories: angiotensin-converting enzyme (ACE) inhibitors, antidepressant agents, antipsychotic agents, benzodiazepines, calcium channel blockers, digoxin, histamine2-receptor antagonists, and nonsteroidal anti-inflammatory drugs. The total number of persons with prescriptions in any of the 8 drug classes increased over the 8-year period, with the greatest growth in ACE inhibitors. Mean annual drug use per person declined in Maryland but increased in Washington and Iowa. Despite increasing use, the overall incidence of prescribing problems fell dramatically in all 3 states, particularly for dose- and duration-related criteria. Except in the area of drug-drug interactions, this elderly population was less likely to have received a prescription falling outside commonly accepted drug utilization review criteria for 8 major drug classes in 1996 than in 1989.
Managed-care programs with utilization reviews may be the best approach to cost cutting. But to really curb costs, providers, insurers, employers and employees must form partnerships to overcome the outrageous inflation in the U.S. health-care system.
Robert J. Becker, M.D., risked his house, his pension, and all the assets from his 26-year medical career to start Health Care Compare, Inc., a Downers Grove, IL, utilization review (UR) company. Since then, Becker has seen that risk pay off. His method of employing physicians as part of the UR team is an attempt to alleviate some of the anxiety physicians have about the UR process.
The proliferation of for-profit health plans has heightened concerns about quality of care, particularly with respect to Medicaid. We undertook this study to compare for-profit and not-for-profit health plans that participate in Medicaid, examining processes of care and the organizational characteristics related to utilization management, financial incentives, and quality of care. Our findings demonstrate that for-profit and not-for-profit plans appear to be more similar than dissimilar in many areas of management, although for-profit plans are more likely to use aggressive utilization review and have slightly less developed quality management systems. On balance, these findings should reassure critics of for-profit health care.
This paper describes a new ambulatory case-mix system developed at The Johns Hopkins University and known as Ambulatory Care Groups (ACGs). ACGs categorize a person into one of 51 categories based on the diseases and conditions for which they received treatment over a period of time, such as a year. ACGs can be used to describe the "illness-burden" of a population and are up to ten times more predictive of ambulatory care resource use than age and sex alone. ACGs can be determined using a computerized "grouper" software package based on ICD-9-CM diagnosis codes and demographic information presently found in virtually all claims or encounter data systems. They were developed and tested at four HMOs and a state's Medicaid program. This paper discusses the potential application of ACGs to analysis, financing, and management of ambulatory care, specifically as it relates to utilization review (UR), quality assurance (QA) and the adjustment of capitation payment within managed care settings.
A multidisciplinary, professional, and administrative approach to selecting therapeutic agents for formulary inclusion--as it is practiced at the Tuskegee Veterans Administration Medical Center--is described. The process by which members of a Drug Utilization Review Subcommittee evaluate drugs is explained in detail. Numerous factors, such as patient population characteristics, total therapy costs, adverse reactions, indications, dosage, and efficacy are considered. Findings, decisions, and economic cost-savings, specifically with respect to antibiotics, are revealed.
Charter Medical Corporation's computerized Clinical Information System is described. The computerized system helps clinicians formulate and document individualized patient treatment plans along the continuum of care and to improve internal medical record keeping. The system can also help improve the efficient collecting, storing, retrieving, and reporting of clinical information, both for internal use and for external utilization review and case management. In the future, the system will be linked to Charter's continuous quality improvement efforts and to its new Clinical Outcome Monitoring System.
PPOs are designed to promote competition among providers for the purpose of enhancing cost containment. Business and industry have demonstrated an active interest in PPOs and report savings as a consequence of purchasing health services for employees from these new alternative care organizations. To be effective in reducing the rate of escalation of personal health care expenditures will require demonstration to the business community that they are able to provide quality care at less cost. This will require a strong utilization review program and a need for providers to share some risk as an incentive to be cost efficient. Furthermore, any federal or state legislation or regulation should discourage overburdensome costs for PPOs to do business.
OBJECTIVES: This study sought to determine the effects of variation in both dentists' decisions to treat and choice of treatment on the costs of care. METHODS: Each of 37 patients was examined individually by several practicing dentists (between 3-22, mean = 6.2). For each dentist's recommended treatment for each patient, the total cost of restorative treatment was calculated first using the least expensive treatment possible for each tooth indicated as needing treatment, and second using the costs of specific treatment selected by each dentist RESULTS: Considerable variation was found among dentists in each patients cost of treatment using both methods. The mean of the median cost per patient of the specific treatment selected was three times larger than the cost per patient of basic treatment. Few dentists were found to consistently recommend higher or lower cost treatment plans. CONCLUSIONS: These findings suggest that inconsistencies in both dentists' decisions to intervene and dentists' selection of treatment can have a profound effect on cost. Further, focusing utilization review on "outlier dentists" is likely to be much less productive in containing costs and improving quality than comprehensive attempts to improve consistency across the profession.
The authors describe the successful development and implementation of a multi-use nursing information system. Developed under the direction of nursing administration, this system serves as a database for statistical analysis, utilization review, and budget management. The intent of the article is to encourage nursing administrators with information systems to use them to the fullest possible extent.