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PubMed1977

The mentally ill in nursing homes. New back wards in the community.

The reduction in state hospital populations in the last two decades is most often attributed to psychotropic medication and community mental health centers. The role the proprietary nursing home has played in this reduction has not been adequately studied. Using data routinely collected for Medicaid utilization review, we studied characteristics of psychiatric nursing home patients in Utah. One third of the nursing home patients had a psychiatric diagnosis; more than half of this group were classified as psychotic. Most psychotic patients were significantly younger than their nonpsychiatric counterparts. Nonpsychiatric patients received a higher mean number of psychoactive drugs than did psychiatric or mentally retarded patients. Over time, all groups of patients showed an increase in prescribed psychoactive medication and a decrease in activity. The consequence of this pattern of care raise serious questions about our current reliance on nursing homes for the care of the psychiatric patient.

Adult↗
PubMed1998

Managing health services: how administrative data and population-based analyses can focus the agenda.

University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for providing answers to such questions as: which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or utilization related to high need? More specifically, this system provides decision-makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and counties, utilization review within a single hospital, and longitudinal research on health reform. A particularly interesting application to planning physician supply and distribution is discussed. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

Canada↗
PubMed1994

Evaluation of a DUR intervention: a case study of histamine antagonists.

Drug Utilization Review (DUR) programs aim to control inappropriate prescribing and drug costs, but there are few rigorous studies of their impact. This paper presents the evaluation results of a DUR intervention (excessive duration of full-dose histamine-2 receptor antagonists) using a quasi-experimental design. We observe a greater reduction of H2RA use in the intervention group than in the comparison group, and a reduction in drug expenditures which exceeded the cost of targeting and notifying prescribers. The success of DUR programs depends on both their efficiency and the drug issues under consideration; the use of a comparison group is critical in the evaluation of their impact.

Ambulatory Care↗
PubMed1995

Improving the quality of antimicrobial drug use can result in cost containment.

Antibiotic policies are implemented to optimize patient care, to limit antimicrobial resistance and to reduce costs. Before improving the use of antimicrobial drugs by monitoring, it is of primary importance to conduct a general utilization review to document problem areas within the hospital and to evaluate quality and costs. Subsequently, limited targets for an intervention can be defined. For the evaluation of quality, established criteria can be used to classify prescriptions into categories of appropriate use. Several classification systems are described in the literature. We have developed a classification method which allows evaluation of each relevant parameter associated with antimicrobial drug use and global (true) cost calculation. Data are processed in a computer program for Apple or Windows. Surgical prophylaxis is a target of choice to analyse at a hospital pharmacy level. Important cost savings can be obtained by implementing well-accepted standards of good antimicrobial prophylaxis.

Anti-Bacterial Agents↗
PubMed1995

The design and analysis of hospital utilization studies.

The reports of hospital utilization review (UR) studies that appear in this issue employ a range of design strategies, and much of the variation seems accidental--arising because there are many acceptable strategies--rather than functional. This paper is about general design strategy: the value of explicit protocols for sampling and data collection, of analyses appropriate to the sampling, of generating reports managers can use. More coordination is strongly encouraged, to reduce unnecessary variation and to facilitate comparisons across studies. While individual groups may still opt for different strategies, techniques for increasing the comparability of reported findings are discussed. This will increase the value of each study, individually, as well as the value of the collective effort.

Bias↗
PubMed1994

Impact of managed care organizations on ethnic Americans and underserved populations.

Health care reform focuses on cost containment, which in turn focuses on managed care organizations (MCOs). MCOs use strict utilization review and financial risk-shifting to assure that doctors and providers act as gatekeepers to health care services. The gatekeepers are assumed to continue to order necessary care and to eliminate only "unnecessary" care. However, significant potential for abuse exists. In fact, the very foundations on which MCO decisions are made are culturally biased, because they are based on information from largely middle-class, European-American, healthy males. Ultimately, MCOs will change the perceptions and expectations of society regarding health care. These altered perceptions may be contrary to the needs of ethnic Americans, and without safeguards, could worsen existing disparities in health status.

Ethnicity↗
PubMed1979

A new intermediate dental outcome measure: amalgam replacement rate.

The length of time amalgam restorations last before replacement was investigated for use as an intermediate outcome measure in utilization review and quality assurance studies. Based on record data from 37 general dental practices, a determination was made of the average percentage of two- or three-surface amalgams receiving another service at 6, 12, and 24 months from the date of insertion. After 2 years, approximately 13 per cent of the amalgams were replaced, and the estimated median life time for amalgams was between 10 and 14 years. The variation in replacement rates among practices was substantial but was not explained by the technical quality of restorations or several practice characteristics.

Dental Amalgam↗
PubMed1996

Pharmacoeconomic comparison of loop diuretics in the treatment of congestive heart failure.

As MCOs explore opportunities for delivering more cost-effective medical care, prioritization based on drug utilization reviews alone may not adequately highlight those disease states that consume a disproportionate share of overall resource cost; the daily cost of pharmacotherapy may not reflect the overall economic effect. As the elderly proportion of the population grows, the treatment of congestive heart failure may represent for MCOs an increasingly important opportunity to achieve acceptable or even improved outcomes while controlling the costs of hospitalization and other resources. The introduction of new pharmaceuticals presents an ongoing challenge for managed care to determine whether they offer a pharmacoeconomic advantage over current treatment regimens. This paper reports on an economic assessment made between a new and an existing loop diuretic in the treatment of congestive heart failure.

Aged↗
PubMed1998

Psychiatrists' duties in discharging sicker and potentially violent inpatients in the managed care era.

Psychiatrists have certain clinical responsibilities and legal duties to patients treated in managed care settings. They include disclosure of all treatment options, the exercise of rights of appeal for any care they believe will materially benefit patients regardless of allocation guidelines or gatekeeper directives, continuance of emergency treatment, and reasonable cooperation with utilization reviewers. An additional duty--to warn and protect endangered third parties--will likely increase as cost-containment measures curtail the length of hospitalization. The author discusses these duties in the context of sicker and potentially violent patients. He cautions psychiatrists to be careful not to prematurely discharge these patients because of pressures from managed care organizations. The policies of such organizations can place psychiatrists and patients in a precarious position by limiting the time and resources for diagnosis and the assessment of the risk of potential violence. These responsibilities and duties often can be turned into clinical opportunities that enhance the therapeutic alliance with patients.

Disclosure↗
PubMed2000

Factors associated with level of care assignment in substance abuse treatment.

Managed-care approaches to controlling expenditures for publicly funded substance abuse treatment have proliferated in the past decade. As many as 40 states now have some type of utilization review mechanism. Many have adopted the American Society on Addiction Medicine placement criteria to assign persons to a level of care. This study examined the use of those criteria with 3,000 consecutive admissions to publicly funded treatment in Kansas and identified variables that predicted level of care assignment. For the most part, the placement domains predicted level of care as expected. However, even when controlling for the contribution of the placement domains, housing status and employment were among the best predictors of placement. These findings suggest a need for criteria that address social service as well as clinical concerns when working with vulnerable populations.

Adult↗
PubMed1999

Using feedback letters to influence the use of antiulcer agents in a Medicaid program.

OBJECTIVE: To determine the impact of printed patient-specific feedback regarding potential misprescribing of antiulcer agents (AUAs). Measures of impact included improvements in patients' dispensing profiles, assessed according to predetermined criteria, and decreases in cost and quantity of AUAs dispensed. DESIGN: Controlled study. After evaluation for compliance with predetermined criteria, prescribers identified as having one or two patient profiles with potential errors were assigned alternatively to control or experimental groups. An intervention was mailed to the experimental group. SETTING: Outpatient setting in the New Mexico Medicaid population. PARTICIPANTS: Patients and prescribers identified as having potential misprescribing of AUAs. INTERVENTION: The intervention consisted of a cover letter describing the purpose of the drug utilization review program, an educational fact sheet regarding prescribing AUAs, patient profiles with potential misprescribing, and physician response forms. MEASUREMENTS AND MAIN RESULTS: There were greater improvements in dispensing to patients in the intervention group (chi2, p <.001). Significant odds ratios for the intervention group were 2.29 for AUAs discontinued, 1.98 for all improvements combined, 13.13 for improvement in listing of proper diagnosis for AUAs, and 2.84 for appropriate indication when prescribing the higher acute daily dosage. Using data from 3 months before and after the intervention, we found greater decreases in mean monthly costs (p =.044) and mean monthly quantity of AUAs dispensed (p =.049) in the intervention group. CONCLUSIONS: This intervention significantly decreased AUA dispensing to patients whose prescribers were mailed the patient-specific feedback intervention.

Anti-Ulcer Agents↗
PubMed2001

Screening inappropriate hospital days on the basis of routinely available data.

OBJECTIVE: The systematic use of regular hospital utilization reviews has proved costly, particularly in countries with short average lengths of stay. This study examines the performance of three tests based on routinely collected data when screening inappropriate hospital days. DESIGN: The Appropriateness Evaluation Protocol was used to set the gold standard. The first screening test was simply based on the comparison of an observed length of stay with a target value; the second test additionally made allowances for surgical and intensive care procedures while the third added the amount of required nursing workload to these data. SETTING: The neurology and general surgery departments of a Swiss university hospital. PARTICIPANTS: Every day of care for all inpatients stays was reviewed to assess the appropriateness of hospital use and submitted to the screening algorithm (9,000 hospital days). MAIN OUTCOME MEASURES: Receiver-operating characteristics curves were compared to optimize the performance of the screening tests. The best test was applied to all units of the hospital and rates of inappropriate days were computed using a Bayesian approach. RESULTS: The first and the second tests have a sensitivity of 66-80% and a specificity of 66-67%. Nursing workload data yield no significant improvement of the screening test. An unbiased estimate of the rate of inappropriate days may be computed. CONCLUSION: The present study provides some evidence that a screening approach is useful, feasible and efficient for detecting inappropriate hospital days.

Data Collection↗
PubMed1997

Clinician reliability and accuracy in judging appropriate level of care.

Accurately assigning children to the most appropriate level of care is widely recognized as important. Managed care companies conduct utilization reviews in which they monitor the level of care to which clients are assigned using written placement criteria. However, no research has examined the ability of clinicians to perform this task. In the present study, 47 child and adolescent clinical profiles consisting of 48 variables were developed. Eighteen clinicians, trained to use their agency's level-of-care guidelines, made level-of-care decisions on these profiles. Their interjudge reliability in assigning a child to an appropriate level of care was close to zero (kappa = .07). There was a small, statistically significant correlation between client placement and actual placement, but chance-corrected agreement between client placement and actual placement was very low (kappa = .09). Implications of these findings for clinical research, practice, policy, and training are discussed.

Decision Making↗
PubMed2005

Hospital utilization, efficiency and access to care during and shortly after restructuring acute care in Newfoundland and Labrador.

OBJECTIVES: Since the 1990s restructuring, including regionalization and downsizing, has largely been driven by a desire for cost containment. Regionalization, hospital closure and changes in management processes occurred in Newfoundland and Labrador (NL), Canada between 1995 and 2000. The objectives of the current study were: to describe trends in the utilization of acute care hospital services by residents of NL during and shortly after restructuring; to examine trends in the efficiency of utilization of acute care beds in the province during the same time frame; and to compare the trends in St John's with the rest of the province, taking account of confounding events, in an attempt to understand the impact of aggregation of hospitals in this region. METHODS: Hospital discharge and day surgical data were analysed for all facilities in NL from 1995/96 to 2000/01. Analyses were by facility of service and also by region of residence directly standardized to the provincial population for 1996. Efficiency of bed utilization was examined on three occasions by concurrent utilization review using a modified version of the Appropriateness Evaluation Protocol. Trends in the St John's region (where most tertiary services are located and greater aggregation of hospitals occurred) were compared with the rest of the province. RESULTS: Admissions declined by 14% in St John's facilities and by 17% elsewhere. Inpatient days fell by 9% in St John's and by 12% elsewhere. Average length of stay and Resource Intensity Weight changed little, apart from a rise in the final study year, with the largest change in St John's. Standardized hospital admission rates declined by 10% and inpatient days by 5.6% for residents of St John's region, and by 16% and 14% respectively for residents of other regions. There was no change over time in the use of day surgery. Efficiency of acute care bed use improved in 2002 in St John's, but was unchanged in other regions. Use of acute care beds by elderly patients for extended stay, or when an alternate level of care would have been appropriate, was greater in St John's with the disparity persisting over time. Waiting time for continuing care in the St John's region was unchanged comparing 1995/96 and 1999/00. CONCLUSIONS: The degree to which acute care restructuring or financial pressures and constraints imposed at the provincial level contributed to observed utilization trends is unclear. Aggregation of hospitals in the St John's region may have contributed to more efficient use of acute care beds. Restructuring as carried out did not integrate health care sectors, and problems at the acute care/continuing care boundary were not resolved in St John's, where access to continuing care remained difficult.

Adult↗
PubMed1993

Institutional responses to Medicare's prospective payment system.

The introduction of Medicare's prospective payment system (PPS) meant an important change in the environment of US hospitals. The new payment system was expected to improve clinical and non-clinical efficiency in hospitals. A case study in a non-profit Pennsylvania hospital was performed to analyse the impact of PPS on hospital services. The hospital responded to PPS by a twofold strategy. First, attempts were made to achieve effective cost containment by improving the efficiency of intermediate and final outputs. Here special attention is paid to the activities of the DRG coordinator and the Utilization Review Committee and to the activities of nurses in their role as case manager. The second strategy was directed at revenue enhancement, initially mainly by shifting more costs to non-Medicare patients and later by trying to strengthen the position of the hospital in the local health care market. This second strategy was considered more important than the strategy of cost containment. With respect to organizational structure and policy-making, the following changes can be observed: a growing importance of strategic management; more integrated hospital-physician relationships; and the development of an adequate medical information system and a medical records department.

Cost Control↗
PubMed2002

Characteristics of eye care practices with managed care contracts.

OBJECTIVES: To describe the variation in practice structure, financial arrangements, and utilization and quality management systems for eye care practices with managed care contracts. STUDY DESIGN: Cross-sectional survey of 88 group and 56 solo eye care practices that contract with 6 health plans affiliated with a national managed care organization. The survey contained modules on practice structure, financial arrangements, utilization management, and quality management. The survey response rate was 85%. RESULTS: Group practices with both ophthalmologists and optometrists were triple the size of ophthalmology-only groups, and 5 times the size of optometry-only groups. Fee-for-service payments were the primary source of group practice revenues, although 60% of groups derived some revenues from capitation payments. Group practices paid their physicians almost exclusively with fee-for-service payments or salary arrangements, with minimal capitation at the individual level. Almost no practices used both capitation and bonuses to compensate providers. Most practices received practice profiles and three fourths were subject to utilization review, which mainly consisted of preauthorization for procedures, tests, or referrals. Nearly all practices used clinical guidelines, protocols, or pathways in managing patients with diabetic retinopathy or glaucoma. Further, nearly all group practices used computerized information systems to assist in delivering care, and most had provider education programs. CONCLUSIONS: Managed care has affected the way eye care providers organize, finance, and deliver healthcare. In general, our findings paint an optimistic picture of eye care practices that contract with managed care organizations. Few practices bear substantial financial risk, and nearly all practices use quality management tools that could help to improve the quality of care.

Capitation Fee↗
PubMed1995

Appropriateness of hospital use: an overview of Italian studies.

This paper reports on the general features and findings of 11 studies conducted in Italy on appropriateness of hospital admission and days of stay using the Appropriateness Evaluation Protocol (AEP). Studies have been grouped for presentation in two categories. The first comprises six heterogeneous studies illustrating different ways of targeting the use of the AEP: two used it to assess appropriateness of admission in an emergency room setting, two measured appropriateness of days of stay in patients with AIDS and nosocomial infections and finally two others evaluated hospital days in a group of elderly patients and "before and after" the institution of a domiciliary nursing service, respectively. The second group comprises five more homogeneous utilization review studies aimed at assessing inappropriateness of admissions and days of stay in medical/surgical departments of large hospitals in northern Italy. Besides detecting a substantial amount of inappropriateness in admission (range = 25-38%) and days of stay (range = 28-49%) this latter group of studies suggests that delays in execution and reporting of laboratory investigations, unavailability of operating rooms and delays due to difficulties in transferring patients to long-term care facilities are the most common causes of inappropriate days of stay. Despite the differences in their objectives, design and methods of sampling, these studies indicate that an explicit, diagnosis-independent and standardized instrument such as the AEP can help to uncover a substantial amount of the potentially avoidable use of hospital resources in the Italian context.

Health Services Research↗
PubMed1998

Managed care organization liabilities.

While certain efficiencies and cost savings have been achieved, Managed Care Organizations (MCOs) have risk exposures never before considered. MCOs provide a number of services for their clients. Specifically, they are involved in credentialing, network development, utilization review, and the hiring and firing of physicians and other allied medical professionals subject to rather complex and detailed contractual arrangements. The insurance industry has responded to the increase in claim exposure associated with the aforementioned activities by providing any number of insurance products. Depending on the insurance provider, a number of different coverages are available. The final decision as to which coverage to purchase will be governed by the risks associated with a particular MCO, contractual protections, available cash flow, protections under federal and state laws. The point of this article is to apprise MCOs of the claims now starting to develop against MCOs as well as alternative insurance products that can be purchased in order to protect both the firm's assets as well as those of individual directors and officers.

Allied Health Personnel↗