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PubMed1991

Hospitals eyeing physicians' practice patterns. Economic credentialing is being tested to reduce expenses and improve quality.

In an effort to reduce expenses and improve the quality of medical care, some hospitals are turning to economic credentialing. They believe utilization review and peer pressure can alter physicians' inefficient practice patterns without threatening their clinical privileges. But executives of a two-hospital system employing credentialing say the threat of losing clinical privileges is the best way to remind physicians to comply with hospital standards.

Attitude of Health Personnel↗
PubMed1987

Preferred provider organizations. Implications of the fastest growing health care option.

Preferred provider organizations (PPOs) are a new delivery arrangement that affords the consumer flexibility in choosing providers, while offering financial incentives to use preferred providers (both hospitals and physicians). These providers, who contract with a PPO, must agree to utilization review and usually accept a discounted charge as payment. Preferred providers do, however, benefit from an increased patient base and more rapid claims payment while remaining in the fee-for-service sector. The article examines this innovative delivery approach and discusses potential implications for primary care physicians.

Fee Schedules↗
PubMed1995

Antidepressant utilization in managed care: an evaluation of SSRI use in two HMO settings.

Antidepressant costs and utilization are growing rapidly as newer selective serotonin reuptake inhibitors (SSRIs) comprise an ever-increasing share of the market. A number of factors and related costs must be considered when evaluating antidepressant products. An antidepressant drug utilization review study performed in two different HMO models revealed important variations among available SSRI therapies in terms of dosage escalation and discontinuation, as well as concomitant medication costs associated with treating side effects. New antidepressants may alleviate some of these problems.

1-Naphthylamine↗
PubMed1995

Managed care as a public cost-containment mechanism.

This article identifies the impact of managed-care reforms on the utilization of medical services within the military health-services system. The data come from a recent demonstration project that substituted an HMO and PPO for traditional FFS arrangements. Results from a semiparametric model indicate that the generosity of benefits in the HMO increased demand for ambulatory services. Unlike the private-sector experience with managed care, aggressive utilization review did not significantly curtail inpatient stays. These results vitiate the presumed effectiveness of reform strategies that rely on large, geographically diffused managed-care networks to contain public-sector health costs.

Cost Control↗
PubMed1997

You can safely skip the LDH and save thousands.

Walter Reed Army Medical Center ran a utilization review study on lactate dehydrogenase testing and concluded it's not needed to rule out myocardial infarction. Not performing 6,177 tests saved the hospital $47,000. Nearly 3/4 of hospitals perform unnecessary tests routinely. National guidelines have recommended against routine LDH testing since 1990.

Diagnostic Tests, Routine↗
PubMed1987

Preferred provider organizations one year later.

One year ago we conducted the first comprehensive national survey of preferred provider organizations (PPOs). Results of this study demonstrated that, contrary to popular belief, there did indeed exist a "generic" PPO with clearly defined characteristics. Furthermore, we found that this new form of health delivery organization was rapidly expanding. A new national survey, completed in September 1986, shows continued brisk growth in the number of persons eligible to use PPO services. Utilization review programs have become more stringent and increasingly focus on physician practice patterns. One striking finding is that joint ventures between provider-sponsored PPOs and commercial insurers are multiplying.

Cost Control↗
PubMed1995

Redefining the general psychiatrist: values, reforms, and issues for psychiatric residency education.

The structure and content of general psychiatric residency education must be redesigned to ensure the continued relevance of the profession of psychiatry as managed care and cost containment become more influential in the health care delivery system. The general psychiatrist in this new health care environment must be prepared to participate in a multidisciplinary team of health care professionals, have expertise in treating complex cases that often combine physical and psychological disorders, critically examine the role of psychotherapy, acknowledge patients as active participants in treatment, and integrate clinical and financial decision making. Reformed psychiatric residency curricula should include an expanded range of training settings, preparation for a variety of clinical roles, practice in developing strategies for improved service utilization, and opportunities to develop expertise in neuropsychopharmacology, to work with patients with serious mental illness, and to practice integration of psychotherapy with other core skills. In addition, redesigned curricula should enhance residents' appreciation of the interaction between patients' everyday behavior and mental illness and should provide training in supervision and in utilization review. Redefinition of the structure and organization of psychiatric residency education will depend on the resolution of several key issues such as length of training, financing of graduate medical education, and the role of subspecialization programs.

Cost Control↗
PubMed1996

Central dimensions of clinical practice evaluation: efficiency, appropriateness and effectiveness--I.

Successful audit of clinical practice focuses upon the systematic investigation of key aspects of the everyday work of busy clinicians. We contend that the nature and quality of local clinical practice can be characterized by critical examinations of the effectiveness and appropriateness of practice and the efficiency with which effective, appropriate clinical care is delivered to patients. When such a baseline has been established, it becomes possible to compare and contrast characterized local practice with so-called 'evidence-based' practice and agree changes aimed at narrowing the discrepancy between the two. The nature of such changes can be described and their implementation into practice studied, with subsequent quantitative measurement and qualitative description of the resulting benefits to patients. A proper understanding of the concepts of efficiency, appropriateness and effectiveness in clinical care is clearly fundamental to the successful design and applications of methodologies aimed at securing measurable improvements in the quality of patient care. In this first of two articles we examine the concepts of efficiency and appropriateness in clinical practice, with particular emphasis on cost-effectiveness and utilization review. The clinical effectiveness of health care intervention is treated in detail within the second paper, to be published within Volume 2 Number 2 of the Journal of Evaluation in Clinical Practice (Miles et al. 1996f).

Clinical Medicine↗
PubMed1989

Evolution of DRGs and clinical information systems.

DRG definitions have evolved during the past decade and will continue to evolve as methods for evaluating severity data become available. The use of DRGs for hospital budgeting, payment and evaluation as well as the support of hospital utilization review and quality assurance activities requires that systems be available to insure data quality. A comprehensive and flexible clinical information system will be required by hospitals in order to manage under a DRG system.

Adult↗
PubMedDate not supplied

Choosing a patient classification system to describe the hospital product.

Managers and physicians need additional tools to define the hospital's product other than diagnosis related groups (DRGs), one of several patient classification systems. DRGs are one way to define the hospital product, the treated patient, and are useful in assessing the profitability of Medicare cases. For other management activities--pricing, developing physician practice profiles, utilization review, and quality assurance--a more relevant and homogeneous patient category may be needed. This article discusses general classification concepts as well as a process for hospital managers and physicians to choose and modify patient classification systems that fit their particular situations.

Costs and Cost Analysis↗
PubMed2005

Clinical audit of linezolid use in a large teaching hospital.

OBJECTIVES: Linezolid, the first available agent in the new class of oxazolidinone antibiotics, represents a significant advance in the management options available for combating methicillin-resistant Staphylococcus aureus (MRSA) infections. In the UK it was launched for clinical use in 2001. The aim of this study was to audit the clinical use of linezolid and compliance with the guidelines of the hospital antibiotic committee. METHODS: Our hospital antibiotic committee agreed clinical indications for linezolid use. We undertook an audit of compliance with these recommendations and also reviewed its use in terms of the source of infection, microbiology, duration of therapy, side-effects and choice of previous treatment. RESULTS: Seventy-seven inpatients prescribed linezolid in Ninewells Hospital in the 3 years between March 2001 and September 2003 were audited. Overall compliance with our local recommendations appears to be very good. The main justification for using linezolid is the presence of existing or worsening renal dysfunction or poor venous access (34%) or lack of tolerance or clinical failure following glycopeptide monotherapy or combination therapy (32%). Skin and soft tissue infections (26%) were the most frequently diagnosed infections, although an increasing number of patients appear to receive linezolid for the treatment of lower respiratory tract infections, primarily in the ICU for nosocomial or ventilator-associated pneumonia. MRSA organisms were the most common cause of microbiologically proven treated infections [n = 43 (56%)]. Disappointingly, only 34 out of 77 patients had case record documentation of prior approval by an infection specialist. CONCLUSIONS: The use of linezolid in our hospital appears to follow local guidelines, but the quality of information recorded in the notes could be optimized. Consequently, a linezolid mandatory order form to be completed by the attending prescribing clinician has been introduced, and will be subject to future evaluation. We recommend such specific antibiotic utilization reviews or audits of new agents introduced into clinical infection practice.

Acetamides↗
PubMedDate not supplied

Converging pathways: a journey toward quality case management.

Development of case management as a profession surged in the latter part of the last century, due in large part to the birth in 1990 of two quality-focused organizations. In that year, URAC was established to improve the quality and the accountability of organizations conducting utilization review, but, in later years, it expanded to accreditation of organizations conducting many medical management components, such as case management and disease management. Today the organization has 17 accreditation programs.

Accreditation↗
PubMed1998

Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State.

OBJECTIVE: To examine back and neck hospitalizations in the Province of Ontario and Washington State. Because of their different organization and financing, there has been considerable interest in comparing healthcare systems in Canada and the United States. Features of healthcare systems might be expected to result in greater variations in care for elective than urgent conditions. DATA SOURCE: Automated hospital discharge databases. STUDY DESIGN: Previously developed algorithms were used to identify surgical and nonsurgical hospitalizations for back and neck problems in the administrative databases. We compared overall rates of hospitalization and lengths of hospital stay in Ontario and Washington as well as small area variations within the province and state. PRINCIPAL FINDINGS: Surgical back and neck hospitalizations were three times as common in Washington, but medical hospitalizations were twice as common in Ontario. Provincial lengths of stay were longer for both surgical and nonsurgical hospitalizations. Admission rates varied substantially and significantly among small areas in both Washington and Ontario. Variations in hospital length of stay were greater in Ontario, particularly for nonsurgical back and neck hospitalizations. CONCLUSION: The two jurisdictions had very different patterns of hospital utilization for one of the most common health problems seen by physicians. Our results suggest that the global controls on hospital budgets and access to technology in Ontario were associated with lower rates of surgery, higher rates of hospital-based medical care, and longer lengths of stay. They also indicate that the utilization review process in Washington was associated with lower small area variation rates for medical back care.

Adult↗
PubMedDate not supplied

Physician profiling decreases inpatient length of stay even with aggressive quality management.

It has been well demonstrated that physician profiling for specific diagnosis-related groups or critical interventions modifies physician behavior. The question this study evaluated was whether the addition of a physician profile that displays average length of stay for all cases admitted to the hospital for the defined period of time modified physician practices in an institution that has well-organized and well-integrated Quality Management, Utilization Review, Discharge Planning, and Social Work Departments. The results of this study demonstrate a positive effect of the physician profile in regard to changes in average length of stay.

Benchmarking↗
PubMed2000

Risk sharing and the supply of mental health services.

This paper examines the effects of risk sharing with mental health providers in a managed care context. The results show that providers that received a fixed payment per case reduced the number of outpatient visits by 20-25%, compared with providers who continued to be paid for each visit. This effect was stronger for integrated group practices and providers with more intensive utilization review protocols. In addition, evidence was found that in a setting where providers serve multiple payers, the share of their total revenue derived from risk-sharing contracts is an important determinant of the magnitude of the supply response.

Adolescent↗
PubMed1997

The relationship between the supply of cardiac catheterization laboratories, cardiologists and the use of invasive cardiac procedures in northern New England.

OBJECTIVES: Utilization rates of coronary angiography and cardiac revascularization have been found to vary between areas. This study addresses the relationship between resource supply and procedure rates. METHODS: We compared the association of per capita catheterization laboratories, per capita cardiologists and multi-provider markets (where more than one hospital offers coronary angiography services) with the utilization rates for angiography and cardiac revascularization in northern New England, USA. Administrative data were used to capture invasive cardiac procedures. Small area analyses were used to create coronary angiography service areas. Linear regression methods were used to measure associations between the resource supply and utilization rates. RESULTS: Variation in the use of invasive cardiac procedures was strongly associated with the population-based availability of catheterization facilities and multi-provider markets and unrelated to cardiologist supply or need (as reflected in the hospitalization rates for myocardial infarction). In the multivariate model, an increase of 1 catheterization laboratory per 100,000 population was associated with an increase in the angiography rate of 1.62 per 1000 population; those service areas with multi-provider markets were associated with an additional increase in the angiography rate of 1.27 per 1000 population (R2 = 0.84, P = 0.0006). There was a moderately strong relationship between the catheterization laboratories per capita and the revascularization rates (R2 = 0.43, P = 0.029). Angiography rates were highly associated with cardiac revascularization rates: an increase in the angiography rate of 1 per 1000 population was associated with a 0.46 per 1000 increase in the cardiac revascularization rate (R2 = 0.85, P = 0.0001). CONCLUSIONS: Our work suggests that current efforts to address variation in cardiac procedures through activities such as appropriateness criteria, guidelines and utilization review are misdirected and should be redirected towards capacity, in this case the supply of catheterization facilities.

Cardiac Catheterization↗
PubMed1996

HMO strategies for managing workers' compensation claims.

Health maintenance organizations (HMOs) have become very active in managing workers' compensation medical expense benefits. A survey of 316 HMOs shows that this activity takes the form of various network models and a range of services--such as utilization review and case management--that may not be linked to a provider network. Of the HMOs surveyed, 78 reported that, by using managed care services and provider discounts, they were able to save from 20 percent to 30 percent on occupational health claim costs.

Case Management↗
PubMed1996

Riding a Trojan horse: computerized psychiatric treatment planning using managed care principles.

Efforts to curtail health care costs have triggered new emphasis on resource management and accountability, entailing explicit documentation of the rationale for treatment and the resulting outcome of care. This article discusses the development of a computerized psychiatric treatment planning database that embodies principles and language of managed care, including specific admission criteria, severity ratings, and time frames for completion of interventions. The program is designed to balance goals of clinical utility, usefulness of the database as a tool for utilization review, quality improvement, and health services research, while providing an interface that is acceptable to clinicians.

Case Management↗