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PubMed1994

Influence of the acquired immunodeficiency syndrome on resource availability in critical care medicine in the coming decade.

Information presented regards the consumption of resources in the management of critically ill patients with the acquired immunodeficiency syndrome (AIDS). Predictions are made about future increases in critical care services for patients with this condition. While increased need will primarily be related to an increased number of patients with AIDS, an expanded need for critical care services is also likely to result from changes in the populations at risk and in the presentation of the syndrome. In particular, the relationship between the AIDS epidemic and tuberculosis is described. The balance between AIDS research costs and the care of patients with the syndrome, as well as the availability of resources, is likely to become less favorable as healthcare reform unfolds. A number of suggestions for coping with this imbalance include efforts to achieve better selection of patients for ICU admission and to employ aggressive therapies and alternative treatments that do not require ICU admission. Creative administrative planning, including the use of case management, therapist-driven protocols, intensified utilization review, regionalization, and expansion of home health services, is discussed. It is necessary for clinicians to demonstrate that therapies result in survival and other substantial benefits. The need to keep legislators informed of new achievements in critical care and a new focus on preventive care are emphasized.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

Bundling services saves everybody time.

From a practical viewpoint, the close relationships among utilization review, quality assurance/improvement, infection control, discharge planning, social services, and medical records makes it impossible to separate them. Case management combines these traditionally isolated hospital functions into one department in order to perform many related functions simultaneously. It provides a much more effective and efficient method than can be accomplished by the traditional institutional approach.

Centralized Hospital Services↗

PubMed1989

Managed health care and the Massachusetts experience.

Managed health care, through prepaid health delivery systems and utilization review organizations, is perhaps the greatest trend in modern health care. The authors examine the remarkable growth of managed care and outline its clinical, economic, ethical, and practical implications. They then review examples of how organized psychiatry has been involved in managed care and describe the efforts to date of the Massachusetts Psychiatric Society in this area. Managed care is here to stay. The future climate of psychiatric practice and the care available to psychiatric patients are dependent on informed and organized activities by psychiatrists and their local and national representatives.

Delivery of Health Care↗

PubMed1978

Monitoring drug therapy in skilled nursing facility patients.

A discussion of one system designed for monitoring drug therapy in skilled nursing facility (SNF) patients is presented. This system will enable the pharmacist to fulfill the federal requirement for monitoring drug therapy and will provide the opportunity for gathering and analyzing drug usage data in fulfillment of the facility's utilization review requirement. The system described was developed and tested at five SNF's. Follow-up studies at each of the five facilities were then performed for comparison purposes. The data presented describe and analyze the results from both studies for two of the ten drugs studied: digoxin and hydrochlorothiazide. The high rates of nonconformance to the established criteria are discussed and specific insights as to why drug therapy in these patients often seems inappropriate are provided.

Digoxin↗

PubMed2005

Examining nurses' decision process for medication management in home care.

BACKGROUND: The process of medication management within home care agencies was prospectively described, with a focus on the nurse's role and critical points in the process. The process the nurse must follow includes preparing, checking, and administering medications; updating knowledge of medications; monitoring the effectiveness of treatment; reporting adverse reactions; and teaching patients about their drugs. PROCESSES FOR MEDICATION MANAGEMENT IN HOME HEALTH CARE: The steps that home health nurses (HHNs) go through with families and the system changes that could be developed to decrease errors were identified. The approach was based on Failure Mode and Effects Analysis-a method to identify and prevent process problems before they occur. The medication management process was divided into drug utilization review (DUR) for duplicative and harmful interactions; drug administration by the patient, family member, and/or caregiver; and side effects. Failure modes were developed for a DUR for duplicative and harmful interactions. DISCUSSION: Home health agencies should analyze the medication management process in their own agencies and identify system solutions. The difficulty encountered by HHNs in contacting physicians to discuss changes to the drug regimen following the assessment of potential drug interactions or duplications is an ongoing problem. Careful monitoring by HHNs could decrease the impact of adverse drug effects.

Decision Making↗

PubMed1998

The Asthma Outreach Project: a promising approach to comprehensive asthma management.

We describe a pilot system of coordinated asthma care emphasizing home visits by a community-based lay worker collaborating with a pediatrician, pharmacist, and public health nurse. Study participants included 23 low-income children with moderate to severe asthma and their families at an inner-city pediatric clinic. This system was successfully implemented, and client satisfaction was extremely high. Utilization review showed a reduction in hospitalizations, emergency department visits, and unscheduled clinic visits, and an increase in follow-up clinic visits. This model of care may reduce unscheduled service use and deserves further study as an alternative for asthma management among similar patient populations.

Asthma↗

PubMed1995

Medical appropriateness of hospital utilization: an overview of the Swiss experience.

We present here the principal results of four concurrent hospital utilization reviews conducted in Switzerland in 1990 and 1991, based on an adapted Appropriateness Evaluation Protocol. The studies were performed on all the hospital days from a sample of patients admitted over a 6 month period. The level of inappropriate use ranged between 8 and 15% in terms of days and was consistently higher in medicine than in surgery. In comparison with other published studies, the low proportion of observed inappropriate days is probably due, at least partly, to differences in study design.

Bias↗

PubMed1991

Employer health care plan design and its effect on plan costs.

This study uses claims data from employers in the Houston Area Health Care Coalition (HAHCC) for 1985 through the first half of 1987 to examine the effect of health care plan attributes on health care costs. Plan attributes affect the site of care and the costs of care. Utilization review clearly was effective in reducing the demand for inpatient services, but that reduction was in large measure matched by increases in care in the outpatient setting. Restrictions on mental health benefits also shifted the site of care. In contrast, neither premium sharing nor the plan's deductible had a significant impact on total plan charges. The study results demonstrate the need to have a comprehensive cost management strategy.

Adolescent↗

PubMed2006

The big bang? An eventful year in workers' compensation.

Workers' compensation in the past two years has been dominated by events in California, which have been so fundamental as to merit the term big bang. Passage of Senate Bill 899 has led to a comprehensive program of reform in access to medical care, access to rehabilitation services, temporary and permanent disability, evidence-based management, dispute resolution, and system innovation. Two noteworthy developments thus arose: a new requirement for apportionment by cause in causation analysis, and the adoption of evidence-based criteria for impairment assessment, treatment guidelines, and, soon, utilization review. Elsewhere in the United States, changes were modest, but extensive legislative activity in Texas suggests that Texas will be next to make major changes. In Canada, the Workers' Compensation Board of British Columbia has adopted an ambitious strategic initiative, and there is a Canadawide movement to establish presumption for certain diseases in firefighters. Suggestions for future directions include an increased emphasis on prevention, integration of programs, worker participation, enhancing the expertise of health care professionals, evidence-based management, process evaluation, and opportunities for innovation.

British Columbia↗

PubMed2002

Are longer hospital stays beneficial for the elderly?

Utilization review is a way to manage healthcare costs and is widespread in Canada, as managers attempt to use available acute-care beds in a best practice manner. As we reduce beds and decrease length of stay, we often wonder if the outcomes for patients are affected, particularly if the patients are elderly.

Aged↗

PubMed1999

Patients' increased severity of illness drives up LOS around the country.

For the first time in two decades, lengths of stay at hospitals across the country are creeping upward, thanks to a corresponding increase in the severity of patients being treated in the acute care setting. Some experts say this trend is solid evidence that traditional utilization review has outlived its usefulness and must be replaced by more effective cost-containment efforts. While case management traditionally is oriented toward reducing overutilization, experts say underutilization of resources can hurt your bottom line, too, if it's having a negative effect on patient care. A second, largely untapped source of potential cost savings is identifying and addressing misutilization, namely medication errors and other mistakes that invariably lead to higher treatment costs--as well as possible litigation expenses--down the road.

Case Management↗

PubMed1993

Utilization managers in Medicare risk contract HMOs: from control to collaboration.

A study of utilization management (UM) practices in 13 health maintenance organizations (HMOs) with Medicare members was undertaken as part of an evaluation of the Medicare Risk Contract strategy. Although there were significant variations among HMOs, the common challenges of managing care for this particular population also led to important similarities. Most notable was the emphasis on redirecting the focus of control-oriented utilization review to promotion of continuous improvement in care management. The multiple medical and social service needs of Medicare beneficiaries have forced HMOs to cultivate close collaboration with physicians and UM personnel. Thus, UM personnel are involved throughout the continuum of care and play an important role in assisting HMOs to approach the "seam-less delivery system" ideal. HMOs report that the experience of managing care for Medicare members has made them more responsive to serving all of their members and to promoting long-term partnerships with their physicians.

Aged↗

PubMed1994

The oversight of medical care: a proposal for reform. American College of Physicians.

The oversight of medical care, in the form of peer review, has traditionally been used to ensure that the highest standards of care are maintained. What is relatively new is the external oversight of medical practice carried out by a growing number of independent entities (government, third-party payers, for-profit firms, for example), overseeing care in uncoordinated ways. Tensions arise when reviews of utilization and reviews of quality are conducted by different organizations with conflicting goals. The review instruments are still crude and have neither been adequately tested nor validated. Future attention to developing reliable and valid measures of efficiency and quality is essential. Evidence suggests that the principal process of review, the case-by-case review, may not be cost-effective and may not be conducive to improving quality. It should be replaced by profiles of practice patterns at institutional, regional, or national levels. We propose a model of oversight that emphasizes the appropriate balance between internal mechanisms of quality improvement and external accountability. In this model, internal and external reviews have specific, complementary roles that promote efficiency and quality. Detailed monitoring of quality and problem solving are left to providers who are intimately involved with care. In return, they become accountable to payers and the public through the surveillance of patterns of practice.

Health Care Reform↗

PubMed1999

Increase coordination, effectiveness of CM.

Concerned about insurance denials and late discharges, administrators at Alamance Regional Medical Center in Burlington, NC, chose to merge two of its departments--patient and family services, and utilization review--to create a case management department. The thought was that by working as one department, staff could integrate work processes and capitalize on their existing resources. Regular staff meetings were held to solicit input from members of both departments on the merger. Communication among staff improved greatly after implementation of an informal daily report in which the team members discuss their activities and perspectives for each patient to ensure that their efforts are coordinated. Team members also participate in more formal discharge planning meetings held in each unit.

Case Management↗

PubMed1997

What do managed care plans do to affect care? Results from a survey of physicians.

Little is known about physicians' exposure to managed care techniques that affect clinical practice. In 1995, we conducted a survey of 2,003 U.S. physicians asking them about their share of patients subject to a variety of managed care techniques. Nationally, 24% of physicians received some form of capitation payment for their patients. The two most widely used techniques were utilization review (UR), applied to an average of 59% of patients, and discounted fees, applied to an average of 38% of patients. Although UR was common, ultimate denial rates of coverage were very low: at most 3% for the types of care studied. Use of managed care techniques varied more within states than between states. Conventional measures of HMO market penetration revealed little about how managed care affects physicians.

Capitation Fee↗

PubMed1992

A computerized system for identifying and informing physicians about problematic drug use in nursing homes.

With growing concern over the quality of medication use in nursing homes, physicians, administrators, pharmacists, and regulators are looking for effective and efficient methods to improve it. Pharmacy consultation alone appears to be ineffective in controlling the use of inappropriate drugs. We describe here a computerized drug utilization review system designed for use in nursing homes. The system evaluates the appropriateness of medication use by criteria developed through the consensus of experts in geriatrics and specifically designed to address the pharmacological needs of elderly, nursing home residents. The program not only determines the frequency of inappropriate prescriptions, but produces written, educational statements to be given to prescribing physicians. These statements can also be given to nurses to educate them about issues in geriatrics pharmacology. Additionally, the system produces medication order forms that may help focus physicians' attention on the need to evaluate drugs individually.

Clinical Pharmacy Information Systems↗

PubMedDate not supplied

Computer-generated informational messages directed to physicians: effect on length of hospital stay.

OBJECTIVE: With the advent of hospital payment by diagnosis-related group (DRG), length of stay (LOS) has become a major issue in hospital efforts to control costs. Because the Columbia-Presbyterian Medical Center (CPMC) has had above-average LOSs for many DRGs, the authors tested the hypothesis that a computer-generated informational message directed to physicians would shorten LOS. DESIGN: Randomized clinical trial with the patient as the unit of randomization. SETTING AND STUDY POPULATION: From June 1991 to April 1993, at CPMC in New York, 7,109 patient admissions were randomly assigned to an intervention (informational message) group and 6,990 to a control (no message) group. INTERVENTION: A message giving the average LOS for the patient's admission or provisional DRG, as assigned by hospital utilization review, and the current LOS, in days, was included in the main menu for review of test results in the hospital's clinical information system, available at all nursing stations in the hospital. MAIN OUTCOME MEASURE: Hospital LOS. RESULTS: The median LOS for study patients was 7 days. After adjustment for covariates including age, sex, payor, patient care unit, and time trends, the mean LOS in the intervention group was 3.2% shorter than that in the control group (p = 0.022). CONCLUSION: Computer-generated patient-specific LOS information directed to physicians was associated with a reduction in hospital LOS.

Analysis of Variance↗

PubMed1996

The impact of managed care on patients' trust in medical care and their physicians.

Social trust in health care organizations and interpersonal trust in physicians may be mutually supportive, but they also diverge in important ways. The success of medical care depends most importantly on patients' trust that their physicians are competent, take appropriate responsibility and control, and give their patients' welfare the highest priority. Utilization review and structural arrangements in managed care potentially challenge trust in physicians by restricting choice, contradicting medical decisions and control, and restricting open communication with patients. Gatekeeping and incentives to limit care also raise serious trust issues. We argue that managed care plans rather than physicians should be required to disclose financial arrangements, that limits be placed on incentives that put physicians at financial risk, and that professional norms and public policies should encourage clear separation of interests of physicians from health plan organization and finance.

Cost Control↗