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PubMed1975

Applying utilization review procedures in a community mental health center.

A large, multiservice community mental health center operates a utilization review program based on a three-level system of chart review by medical records personnel, a utilization review technician, and a committee of clinicians. Review is facilitated by a checklist for use in rating such issues as comprehensiveness, coordination, and quality of care aginst standards of care developed by the director of each service. The incompleteness of charts pulled for review is a continuing problem. But the system makes for efficient review and has various secondary benefits, such as the improvement of medical records. A survey made in the first year showed that staff had mixed feelings about the need for review, but that 60 per cent thought it was helpful all or most of the time.

Attitude of Health Personnel↗
PubMed1980

Health Care Financing Administration--Medicare and Medicaid; utilization review. Proposed rule.

These regulations would revise utilization review procedures for hospitals that participate in the Medicare and Medicaid programs and establish procedures for facilities or programs that provide inpatient psychiatric services to Medicaid recipients under 21 years of age. They would establish standards for conducting review of the health care provided to patients eligible under the two programs, as required by sections 1861, 1902 and 1903 of the Social Security Act. These requirements would apply only to hospitals; proposed revisions of procedures for skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) would be published later. The intent of the regulations is to ensure that services paid for under Medicare or Medicaid are medically necessary and appropriate.

Hospitals↗
PubMed1998

Risk, motives, and styles of utilization review: a cross-condition comparison.

In the United States various forms of managed care have been introduced to control the use of expensive medical services. One of the most prominent involves utilization review of hospital admissions. While reviewing the appropriateness of inpatient treatment is appealing in principle, its application is made difficult by clinical uncertainty. Managed care plans develop and implement review criteria often without the guidance of clear clinical norms of treatment. Under these conditions, we suggest that utilization review organizations (UROs) can be expected to develop "styles" of review that respond to clinical uncertainty, influenced by their experience, professional orientation, and financial incentives. Two review styles are explored in this paper: standardization, where the URO reduces the variance in clinical practices by eliminating those practices that deviate from professional norms and stringency, whereby the URO shifts the distribution of clinical practice as it tries to change the professional norms of practice. Data from a 1992-1993 national survey of utilization review organizations are used to test whether UROs have review styles that systematically respond to organizational attributes, economic pressures, and clinical uncertainty associated with three medical conditions: cardiac catheterization, low back pain, and adolescent depression. UROs were found to adopt more stringent review strategies for conditions with weaker norms of appropriate treatment. Financial incentives and organizational experience are positively related to greater stringency. Standardization responds to professional orientation and organizational experience. Variation in the review styles of UROs has implications for the resulting distribution of clinical practices as well as the equity of access to medical care.

Adolescent↗
PubMedDate not supplied

Air medical transport utilization review in North Carolina.

OBJECTIVE: To perform a review of the collective experience of all hospital-based helicopter ambulances in the state of North Carolina for compliance with utilization review criteria. DESIGN: Flight records of the six members of the North Carolina Aeromedical Affiliation for the months of November and December 1989 were compared with utilization review criteria by an independent reviewer. A secondary review was performed by a staff member for each service. Scene responses and patients flown to a hospital other than the sponsor were evaluated. SETTING: All six hospital-based helicopter services in North Carolina. TYPE OF PARTICIPANTS: All available flight records for November and December 1989. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 756 transports, 747 flight records were available for review. Initial review demonstrated compliance with the criteria for 713 (95.4%) patients; secondary review showed compliance for 18 of 34 flights not meeting initial review, for an overall compliance rate of 97.9%. Compliance rates for scene responses and transports taken to a hospital other than the sponsoring facility were 96.6% and 94.1%, respectively. CONCLUSIONS: Review of all flights over a period of two-months by all six hospital-based helicopter services in North Carolina using utilization review criteria demonstrated a very high rate of compliance with the established criteria.

Aircraft↗
PubMed1994

Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review.

OBJECTIVE: To develop a reliable measure of physician attitudes postulated to influence resource utilization. DESIGN: Statements related to attitudes that may influence resource use were culled from the literature and informal discussions with physicians. SETTING: Academic medical center. PARTICIPANTS: All faculty and housestaff in internal medicine, pediatrics, family medicine, and surgery at an academic medical center were surveyed. The response rate was 59% (n = 428). RESULTS: Exploratory factor analysis of all internal medicine surveys revealed four prominent domains. These closely corresponded with our a-priori hypothesized domains and were interpreted as cost-consciousness, discomfort with uncertainty, fear of malpractice, and annoyance with utilization review. A replication of the analysis using 25 survey items and conducted on the remainder of the data (surgeons, pediatricians, and family practitioners) revealed a similar four-factor solution. Scales were constructed for each of the four domains. Cronbach's alpha ranged from 0.66 to 0.88. Discomfort from uncertainty and fear of malpractice were moderately correlated (r = 0.42); other scale-scale correlations were modest. Of the four attitude measures, only cost-consciousness was associated with lower self-estimates of resource use. Both annoyance with utilization review and fear of malpractice increased as the proportion of time spent in patient care increased. CONCLUSIONS: Although various physician attitudes and beliefs have been hypothesized to influence health services resource use, reliable and valid measures for most of these have not been developed. The authors developed a 19-item survey instrument designed to measure these attitudes reliably. The four scales developed in this study may help identify physician attitudes that are important determinants of physician decision making and help foster a better understanding of physicians' reactions and acculturation to different practice environments.

Academic Medical Centers↗
PubMed1983

Evaluation of a focused dental utilization review system.

It has been suggested that the efficiency of claim-based utilization review systems could be improved by focusing on providers with very high utilization rates. This strategy assumes that 1) high utilizers are more likely to be overutilizers, 2) labeling claims (e.g., "high utilizer") do not bias the review, and 3) the claim review process is sufficiently reliable. These issues were studied in prospective dental utilization review system where dentists submit claims and radiographs to an insurance carrier so that they may obtain treatment authorization. A sample of dentists with very high and moderate utilization rates for amalgams, crowns, and bridges were identified and their pretreatment claims containing these services (N = 553) were collected. Half the services from high and moderate utilizer practices were labeled "high utilizer," and the other half were unlabeled. Seven dental consultants from two large insurance carriers independently assessed the appropriateness of the services (approve or deny) from radiographs. The results indicate that services submitted by dentists with high utilization rates were no more likely to be denied than those with moderate rates, labeling claims did not appear to bias the reviewers, and interconsultant agreement levels for denials seldom exceeded 50 per cent. The study suggests that further development of focused review systems requires a better understanding of the association between utilization rates and overutilization and new methods for improving the reliability of reviewers.

Evaluation Studies as Topic↗
PubMed1975

Utilization review of treatment for suicide attempters.

The authors describe an effort to develop criteria for utilization review of treatment for suicide attempters. Explicit criteria proposed by a panel of experts as essential determinants for hospitalization of these patients were compared with actual clinical practice. It was found that according to the experts' criteria (which were operationalized into rating assessments), over half of the outpatient sample should have been hospitalized. After multiple regression analysis was carried out on the criteria, however, four predictors showed that only 20 percent of the outpatients should have been hospitalized. The authors discuss the issues these findings raise about the criteria of the experts, their utility for research, their validity, and their implications for utilization review.

Decision Making↗
PubMedDate not supplied

Computerized decision support for concurrent utilization review using the HELP system.

OBJECTIVE: Development and evaluation of computerized concurrent utilization review (UR) support taking advantage of a clinically rich computerized patient database. DESIGN: The Automated Support System for Utilization Review (ASSURE) applies the Appropriateness Evaluation Protocol (AEP) Day of Care criteria to computerized patient data in the HELP hospital information system. This paper reports the development, verification, and validation of ASSURE. MEASUREMENTS: Implementation correctness was verified by measuring agreement with a nurse reviewer, using separate sample sets for all 20 criteria for a total of 560 current inpatients. Usefulness in detecting inappropriate days of care was validated by two nurse reviewers who were crossed with manual and computer-assisted review methods in a blocked design for 168 current inpatients. Agreement with reviewers, sensitivity, specificity, positive predictive value, and negative predictive value were measured. RESULTS: Agreement was very good for satisfaction of criteria, and good for appropriateness of day of care. A patient day identified by ASSURE as potentially inappropriate would be twice as likely to be judged inappropriate by a reviewer as a randomly selected patient day. Review of the 10% of patient days identified as potentially inappropriate by ASSURE would identify approximately 21% of the inappropriate days of care. CONCLUSION: ASSURE is a clinically useful tool for screening adult acute care patients for inappropriate days of care, and promises to make a major contribution to reducing health care costs. The prognosis for successful routine clinical use is good.

Artificial Intelligence↗
PubMed1998

Future directions in utilization review: the role of transfusion algorithms.

Transfusion practice guidelines and retrospective utilization review have been ineffective in curtailing the inappropriate use of blood and blood products, particularly in cardiac surgical patients. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at increased risk for excessive perioperative blood loss requiring transfusion of blood products. Recent evaluations have focused on the use of point-of-care coagulation assays for patient-specific therapy. Blood component administration in patients with excessive post-CPB bleeding is generally empiric, in part related to the times required to perform of laboratory-based tests. Methods are now available for rapid, on-site assessment of coagulation assays to allow appropriate, targeted therapy for acquired hemostatic abnormalities. Recent studies indicate that a rapid evaluation of thrombocytopenia and coagulation factor deficiencies, coupled with transfusion algorithms, can facilitate the optimal administration of transfusion-based therapy in patients who exhibit excessive bleeding after CPB. The use of point-of-care assays and transfusion algorithms may provide an effective concurrent method of utilization review of blood products in the surgical setting.

Algorithms↗
PubMed1984

A strategy to reduce drug expenditures with a drug utilization review program.

This paper describes a potential strategy for implementing a Drug Utilization Review (DUR) program aimed at reducing hospital drug expenditures. The importance of this type of program is underscored by the spiraling rise in health care expenditures and the influence of a new drug technology on this rise. The program described here consists of a utilization review program for high cost drugs for which a lower cost alternative exists. An initial retrospective usage and cost analysis must be undertaken to identify those drugs which should be reviewed initially. As the DUR program progresses, additional drugs can be added to the review program. Once the drugs to be reviewed are identified, the first step is to develop usage criteria. This can be accomplished through a review of the literature and consultation with medical and other specialists. Appropriate medical administrative staff approval and endorsement of the criteria should be obtained utilizing various committee structures and other input. The pharmacy staff must also be inserviced on the approved drug usage criteria. After the criteria are finalized, staff pharmacists will contact a DUR pharmacist daily upon receipt of any physician orders for the review drugs. This pharmacist will then compare the prescribed drug use to the approved criteria and contact the prescriber when the usage appears questionable. A lower cost therapy will then be recommended when appropriate. In order to assess the impact of this intervention strategy on drug expenditures, the cost of the initially prescribed therapies must be compared to the recommended therapies. Data should also be obtained on overall drug usage and expenditures to detect shifts in therapy and drug costs. The success or failure of this concurrent DUR program will be highly dependent upon a team approach and cooperation. A program of this type could have a significant impact on hospital drug expenditures in those hospitals where it can be successfully implemented.

Cost Control↗
PubMedDate not supplied

Effects of Medicaid drug utilization review intervention letters.

The state of Texas Drug Utilization Review (DUR) Board, composed of six physicians and six pharmacists, meets quarterly to determine criteria for implementing retrospective DUR. The board agreed to send intervention letters to physicians concurrently prescribing: (1) two histamine2 (H2)-antagonists (H2As) or (2) either any H2A or omeprazole with sucralfate. To measure the effect of these intervention letters, approximately half of these physicians were randomly chosen to receive a letter while the others served as a control group and did not receive letters. This project focused on the H2A or omeprazole with sucralfate intervention letters in a two-step process. Data on concurrent therapy involving two H2As were analyzed separately and these results are not included in this report. Objective one was to examine feedback from the physicians who received the letters, and objective two was to review and compare patient profiles 6 months after the letters were sent. Analysis of Medicaid prescription claims indicated that 190 physicians had concurrently prescribed either an H2A or omeprazole with sucralfate for 222 patients. Ninety-seven physicians (from 117 identified patient profiles) were selected to receive an intervention letter with their patient's profile or profiles, a response form, and a stamped envelope addressed to the Texas Department of Human Services. A 67.5% response rate was obtained. Of these responses, 49.4% agreed with the letter and 29.1% disagreed with the letter. The remaining indicated responses such as "not my patient," they were no longer seeing the patient, or that they did not prescribe the medication in question. (ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1976

The use of utilization review records as a source of data on nursing home care.

Data form the Utah nursing home Utilization Review Program, 1970-73, provide a description of the population of nursing home patients in Utah and changes over time in patient medication and measures of activity. These data are analyzed according to type of care in home: personal, intermediate, or comprehensive. The collection of data in utilization review programs can help to evaluate the quality of care as well as appropriateness of placement, provided the information collected is designed with these ends in mind.

Adult↗
PubMed1989

A performance appraisal system for quality assurance and utilization review fellows.

There is now increased interest in developing continuing education and career training programs in quality assurance and utilization review. These programs frequently involve on-site practicum experiences for which the performance appraisal system described here was developed. Incorporating a new evaluation technology known as the rating grid, this system is discussed here in terms of its underlying rationale, its rating factors, and the observation and scoring factors used by the observer-evaluator. The system can be used by observers to give feedback to physicians and others undergoing training in quality assurance and utilization review.

Clinical Competence↗
PubMed1994

Guidelines for blood utilization review.

Hospitals are required by accrediting agencies to perform blood utilization review. Specific areas that must be addressed are the ordering, distribution, handling, dispensing, and administration of blood components. Monitoring the effects of transfusion on patients is also required. The format of the review process and the criteria for appropriate blood utilization must be developed by each institution. This article provides examples of areas that can be reviewed and procedures that may be used. However, the suggested laboratory values must not be interpreted as defining indications or criteria for transfusion. Each transfusion committee, or its equivalent, is responsible for developing its own institutional blood utilization procedures and audit criteria. Review and approval by the medical staff prior to implementation are essential. The procedures must also be reviewed and revised on a regular basis.

Blood Transfusion↗
PubMed1987

Survival planning: utilization review and effective case management.

Significant changes have occurred in the patterns, preferences and regulations governing the health care system. Encumbered with a growing list of utilization restrictions and reimbursement limitations, many hospitals have been forced to close. As lengths of stay decline and reimbursements diminish, hospitals must enhance their utilization review process to provide for more cost-efficient medical management. This article presents a utilization review program tailored for this environment.

Hospitals↗
PubMed1991

Effect of hospital utilization review on medical expenditures in selected diagnostic areas: an exploratory study.

Quarterly claims data on 43 insured groups were analyzed through multivariate techniques to explore whether the effects of hospital inpatient utilization review vary across selected broad diagnostic areas. Findings suggest that utilization review was associated with decreases in expenditures of approximately 15 percent for diagnoses within the surgical area, a lesser decrease within the mental health area, and still lesser decrease within the medical area. However, these measurements are imprecise both because of the small numbers and the aggregated diagnoses in each category.

Adult↗