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PubMed1996

Current red blood cell transfusion practices.

The appropriate use of blood transfusions remains variable among health-care institutions and patient populations. Transfusion practices are discussed in this article in relation to medical practice guidelines and utilization review. Specific transfusion practices in the settings of intensive care, orthopedic surgery, and open heart surgery are reviewed. A new, promising approach to improving transfusion outcomes is the use of transfusion algorithms. Transfusion algorithms may prove especially useful if they incorporate point-of-care testing that is both physiologic and patient-specific for transfusion decisions. Transfusion algorithms are discussed and data presented for cardiac surgical adults.

Adult↗
PubMed1994

The medical appropriateness of tympanostomy tubes proposed for children younger than 16 years in the United States.

OBJECTIVE: To describe the clinical reasons tympanostomy tubes are proposed for children and to assess their appropriateness. DESIGN: Analysis of data previously collected prospectively by a national utilization review (UR) firm during a two-step UR process to assess the medical appropriateness of tympanostomy tube placement. Nurses interviewed otolaryngologists' and primary care physicians' office staff to collect clinical data. For a randomly selected subsample of cases found inappropriate, we reviewed subsequent interviews of the otolaryngologists by physician reviewers, who looked for possible extenuating clinical circumstances or additional clinical data that might have changed the appropriateness category. SETTING: Otolaryngologists' practices from 49 states and the District of Columbia. PATIENTS: All 6611 children younger than 16 years who were insured by three clients of the UR firm and whose proposal to receive tympanostomy tubes were reviewed by this system from January 1, 1990, through July 31, 1991. The insurance companies in the study insured 5.6 million Americans at the time of the study. MAIN OUTCOME MEASURE: The medical appropriateness of tympanostomy tube surgery according to explicit criteria developed by an expert panel using the RAND/University of California-Los Angeles modified Delphi method. RESULTS: A total of 6429 (97%) of the cases were proposed for recurrent acute otitis media, otitis media with effusion, or both. Making generous clinical assumptions, 41% of the proposals for these reasons had appropriate indications, 32% had equivocal indications, and 27% had inappropriate ones. Considering the additional information available from the subsample review, the proportion appropriate was 42%, equivocal 35%, and inappropriate 23%. CONCLUSION: About one quarter of tympanostomy tube insertions for children in this study were proposed for inappropriate indications and another third for equivocal ones.

Adolescent↗
PubMed1998

Agreement between administrative files and written medical records: a case of the Department of Veterans Affairs.

OBJECTIVES: This study examined the reliability of Department of Veterans Affairs' health information databases concerning patient demographics, use of care, and diagnoses. METHODS: The Department of Veterans Affairs' Patient Treatment files for Main, Bed-section (PTF) and Outpatient Care (OCF) were compared with medical charts and administrative records (MR) for a random national sample of 1,356 outpatient visits and 414 inpatient discharges to Department of Veterans Affairs' facilities between July 1 and September 30, 1995. Records were uniformly abstracted by a focus group of utilization review nurses and medical record coders blinded to administrative file entries. RESULTS: Reliability was adequate for demographics (kappa approximately 0.92), length of stay (agreement=98%), and selected diagnoses (kappa ranged 0.39 to 1.0). Reliability was generally inadequate to identify the treating bedsection or clinic (kappa approximately 0.5). Compared with medical charts, Patient Treatment Files/Outpatient Care Files reported an additional diagnosis per discharge and 0.8 clinic stops per outpatient visit, resulting in higher estimates of disease prevalence (+39% heart disease, +19% diabetes) and outpatient costs (+36% per unique outpatient per quarter). CONCLUSIONS: In the absence of pilot work validating key data elements, investigators are advised to construct health and utilization data from multiple sources. Further validation studies of administrative files should focus on the relation between process of data capture and data validity.

Adult↗
PubMedDate not supplied

[Evaluation of the prescription quality: hospital databases].

Hospital databases can be used to evaluate drug prescription quality with the help of drug utilization review (DUR). A DUR appraises the appropriateness of prescribing by means of explicit criteria established in accordance with evidence-based data, and then suggests interventions designed to modify prescriber's practice. On the one hand, the capacity of the review to show the variations, and, on the other hand, the assessment of the impact of interventions implemented to correct those variations, depend on the quality of hospital databases. This article has two objectives: to identify the required data, both to carry out a DUR and to evaluate its outcomes, and to define the essential qualities of hospital databases.

Canada↗
PubMed1994

The effectiveness of health care cost management strategies: a review of the evidence.

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.

Cost Control↗
PubMed1989

Use of diagnosis related groups for hospital management.

This paper gives an overview on the use of Diagnosis Related Groups (DRGs) for internal hospital management. Some figures derived from a comparative study between 3 university hospitals in Belgium are used to illustrate specific points. Attention is given to cost accounting and cost control on the one hand, and utilization review and quality assurance testing on the other. Costs have been approximated by billed charges. It is concluded that DRGs can effectively be used for hospital management, in addition to hospital financing for which some pressure also exists in Europe.

Accounting↗
PubMed1992

Judicial and legislative responses to cost containment.

Cost containment through reduction of insurance benefits and aggressive utilization review is increasingly risking the sacrifice of good clinical care in the pursuit of financial objectives. This article provides examples of judicial and legislative responses to perceived fiscal intrusions into clinical practice. Principles for asserting clinical goals in the cost containment process are also provided to assist in the inevitable negotiations and battles ahead.

Adult↗
PubMed1995

Pharmacists as agents of change for rational drug therapy.

We analyze what is known and unknown about the contribution of the pharmacist as patient educator, physician consultant, and agent to affect patient outcomes in ambulatory settings. The need for pharmacist services is discussed, as are the theoretical underpinnings and quality of the scientific evidence to support their efficacy. The analysis is conducted in the context of a shift in pharmacists' roles from product to patient orientation as well as recent U.S. legislation mandating enhanced pharmacists' roles via drug utilization review for all Medicaid patients. We conclude with a research and action agenda, calling for stronger research designs in evaluating pharmacists' interventions. The shifting paradigm in the pharmacy profession, coupled with the implementation of the Omnibus Budget Reconciliation Act of 1990, provide unique opportunities for rigorous evaluations of pharmacists as agents of change for rational drug therapy.

Ambulatory Care↗
PubMed1999

Reliability study of the European appropriateness evaluation protocol.

OBJECTIVE: To help to co-ordinate and harmonize research on utilization review in Europe, the US Appropriateness Evaluation Protocol (f¿EP) was adapted for use in the European setting. The aim of this paper is to assess the reliability of the European version of the AEP (EU-AEP). DESIGN: Nineteen English-language medical records were reviewed by a physician reviewer from each of six participating countries: Austria, France, Italy, Spain, Switzerland and the UK. Each of the six reviewers was asked to assess the appropriateness of the 19 admissions and 31 hospitalization days (19 admission days and 12 randomly selected days of hospital stay, excluding days of discharge) using the revised review instrument. To evaluate inter-rater reliability, the kappa statistic was used to measure overall and pair-wise agreement for the assessment of appropriateness of admission and of day of care, respectively. RESULTS: For admission, the overall kappa statistic among the six reviewers was 0.64, with kappa values for each pair of reviewers in the range 0.46-0.86. For day of care, the kappa was 0.59, with pair-wise kappa coefficients in the range 0.25-0.95. CONCLUSION: The observed agreement could be considered substantial, especially if the fact that medical records were hand-written in a language native to only one of the reviewers is considered. Besides all the study limitations, this finding provides at least preliminary support for the application of the EU-AEP as a reliable instrument in the European setting, including application in comparative studies involving two or more countries.

Europe↗
PubMed1991

Pastoral research in a hospital setting: a case study.

Provides a summary of research procedures and outcome data of a utilization review of the pastoral services of a large university medical center. Notes particularly the value of such a project both in terms of concrete knowledge gained and in terms of serendipitous discoveries leading to further research.

Chaplaincy Service, Hospital↗
PubMed1993

Optimizing Medicare reimbursement in skilled nursing facilities.

Effective utilization review (UR) and clear, complete clinical documentation are essential if a skilled nursing facility (SNF) is to capture charges efficiently and bill appropriately to ensure optimal Medicare reimbursement. Authors Micheletti, Shlala, and Greenfield detail how financial managers can assess UR activities and clinical documentation practices to help improve an SNF's profitability.

Documentation↗
PubMed1979

Health care cost containment in West Germany.

The West German health care system has experienced a serious escalation of expenditures since about 1970. For a variety of reasons, many features of the national health insurance program that might have provided restraints on costs were gradually eliminated. Most notably, some restrictions on the supply of physicians and hospital facilities were ended, as was an earlier system of fixed budgeting for ambulatory care services. In addition, legislative and judicial decisions have continually expanded both the benefits and the standard of care that must be provided to publicly insured patients. In 1977, the government passed a Health Care Containment Act which ordered several measures to curb costs: prospectively negotiated ceilings on expenditures for physicians' services, dentists' services and prescription drugs; strengthening of utilization review; composition of a unified fee schedule; small increases in cost sharing and limitations on insurance benefits; and some changes in financing. The reform efforts seem to have had a significant effect, though it is still too early to tell exactly what caused the declining growth rate of health expenditures, and whether the new trend will persist.

Cost Control↗
PubMed1988

Managed care contracts. A primer on how to analyze contracts and avoid the traps: Part 2.

Because many business entities are attempting to increase their control over medical practice, physicians must take extreme care in reading proposed amendments to managed care contracts. Beware of vague language concerning utilization review; contracts that require you to passively accept future contract modifications; innocuous language that may endow the medical director with excessive authority; and unacceptable regulations concerning medical, financial, and administrative records. The author suggests counterproposals that are fair to both business entities and participating physicians. He further recommends maintaining an ongoing discussion between both parties in order to further chances for success.

Contract Services↗
PubMed1991

The impact of managed care on physicians.

This article examines the forces that led to managed care and considers its two main thrusts: traditional indemnity, with controls and constraints through utilization review, and controlled access and reimbursement, as seen in the HMO model. The strategies available to the physician are discussed, suggesting how managed care can itself be managed. Finally, the evolution of managed care is shown to be in a final phase, wherein efficient and effective physicians are identified by computer data for selective contracting, leaving a sizeable minority of (potentially) unemployed physicians.

Contract Services↗
PubMedDate not supplied

Strategies for positioning in the managed health care marketplace.

Managed health care is becoming increasingly common as the demands of cost containment are placed on providers of care. This article defines managed health care, illustrates its continued growth, demonstrates its effect on clinical decision making and reimbursement issues, and suggests strategies for optimal positioning in the managed care marketplace. The hand therapy specialist, whether based in a hospital, an institution-based ambulatory care setting, or a private practice, must be aware of a managed plan's contractual limitations. Parameters discussed are patient length of stay, documentation, reimbursement, patient responsibility, alternatives to conventional treatment protocols, and the potential effects of utilization review on patient treatment. A heightened awareness of managed health care is critical for the manager and practitioner, especially because national health care reform is on the horizon. A provider must be well prepared to ensure delivery of quality care within the myriad restrictions imposed by managed care regulations.

Cost Control↗
PubMed2000

A Department of Social Work uses data to prove its case [corrected].

The introductions of managed care with its emphasis on cost containment has led a Department of Social Work Services at a large urban teaching center to better document and justify its roles. A concrete result was the saving of social work positions during budget cutbacks and downsizing. There is also information in these data to help clarify the differential roles of social workers and utilization review nurses in the hospital case management/discharge planning processes. The system came about because of concerns around cost containment, the need for more systematic discharge planning and the advent of the Prospective Payment System and Diagnosis Related Groups (DRG's) as a means of reimbursement to hospitals.

Budgets↗
PubMed1987

The impact of prepaid medicine on the fee-for-service practice.

It is much more than just a learning process for physicians to understand the benefits offered by a new arrangement. The introduction of capitated medicine into a traditionally fee-for-service medical group is far-reaching, and it will affect even parts of the practice that may have been considered untouchable. The primary consideration of groups discussing prepaid involvement is most often utilization review. While this is very important, there are many other less obvious areas of impact. Quality assurance, practice size and specialty makeup, physician compensation incentives, contract management, data processing demands, fee schedule changes, and patient advocacy are but a few of the many areas that should be taken into consideration by the medical group manager, physicians, and board when making a decision about whether to introduce a prepaid component into a fee-for-service practice.

Fees, Medical↗
PubMedDate not supplied

An opportunity for medication risk reduction, healthcare provider collaboration, and improved patient care: a retrospective analysis of osteoporosis management.

OBJECTIVES: The objectives of this study were to examine the degree to which long-term care providers are compliant with product labeling regarding administration of alendronate in patients with renal insufficiency and presence of, or predisposition to, upper gastrointestinal disorders; and to observe differences, if any, in prescribing patterns between alendronate and calcitonin-salmon nasal spray in skilled nursing facilities. STUDY DESIGN: We studied retrospectively analyzed patient charts, including medication histories and laboratory data. SETTING: Our study comprised 134 skilled nursing facilities from 21 states. PARTICIPANTS: We studied postmenopausal women, age > or =65 years, receiving either alendronate or calcitonin-salmon nasal spray for a minimum of 2 weeks. MEASUREMENTS: Consultant pharmacists reviewed resident charts submitted the following data for each resident: 2-week history of alendronate or calcitonin use, 2-week history of H2 receptor antagonist or proton pump inhibitor use, most recently documented serum creatinine, actual body weight, and date of birth. RESULTS: Of 905 subjects in the analysis, 38.5% (n = 348) did not have documentation of serum creatinine. Of the 267 alendronate patients for whom creatinine clearance could be calculated, more than half had renal insufficiencies of creatinine clearance <35 mL/min/1.73 m(2) (51.3%, n = 137). In addition, despite widespread information regarding caution in using alendronate in patients with upper gastrointestinal disorders, we found that 33.9% (n = 151) of all alendronate patients were concurrently receiving either H2 receptor antagonists or proton pump inhibitors. Although similar results were observed in the residents taking calcitonin, that agent has no precautions regarding its use in the renally impaired or in patients with gastrointestinal disorders. CONCLUSION: Data from this study indicate that long-term care clinicians might not be adequately differentiating patient profiles and safety criteria when initiating residents on osteoporosis pharmacotherapy, as evidenced by similar prescribing trends in both the alendronate and calcitonin groups. Given its package insert's statements regarding use of alendronate in the renally compromised, results from the alendronate group were particularly problematic as a result of the large number of residents with either insufficient renal function or undocumented serum creatinine. These data demonstrate that osteoporosis could be a disease state that should be more closely analyzed through drug utilization reviews and represent yet another opportunity for improved collaboration between medical directors and consultant pharmacists.

Aged↗