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PubMed1987

Changes in payment policies: impact on physicians' office testing.

Recent changes in payment policies include powerful pecuniary incentives to move care from expensive hospital settings to cheaper outpatient sites. Physicians face competition from a growing number of alternative providers in the diagnostic testing marketplace. Given that a concurrent trend involves aggressive utilization review with stiff penalties for noncompliance, physicians are challenged to practice appropriate restraint in ordering and performing tests.

Clinical Laboratory Techniques↗
PubMed1989

Integrating quality assurance and cost accounting to facilitate management efficiency.

A medication error example illustrates how potential labor costs can be calculated, thereby allowing health care administrators to choose the intervention method with the greatest cost/benefit ratio. This method, which can help QA professionals integrate risk management, decision analysis, and utilization review activities, represents the first step in examining cost/benefit ratios with respect to improved patient-care outcomes.

Accounting↗
PubMed1990

Unit-based clinical and organizational indicators for residential treatment.

A psychiatric residential treatment center has developed a system for monitoring and evaluating the quality of care provided. Administrators of the nine residential treatment units of the Devereux Foundation's Edward L. French Center use a standard form to report on a number of uniform clinical and organizational indicators. The data are evaluated monthly by the utilization review committee, quarterly by the quality assurance committee, and semiannually and annually by other administrators, committees, and the foundation's board of trustees. This process has been an effective mechanism for identifying trends and patterns in client care, for improving client care, and for providing clues to relationships among organizational problems.

Hospitals, Private↗
PubMed1995

OBRA '90: the impact on pharmacists and patients.

Two separate studies were conducted in Georgia for this investigation. The first study measured by observation, pharmacists' compliance with the mandates of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) before (December 1992) and after (June 1993) the law took effect in January 1993. The second assessed patient awareness, experience, and degree of cooperation with pharmacists in complying with OBRA '90. Eight chain and four independent pharmacies were recruited for the first study. For the second, a representative sampling of patients answered questions by telephone. Findings from the pharmacy study indicated more streamlined information gathering, more time devoted to prospective drug utilization review, and a 29% increase in counseling frequency in the post-OBRA '90 period. Some changes may be due to increased computer sophistication. The patient survey indicated a lower frequency of counseling than was reported in the pharmacy study. Patients appeared willing to supply information to pharmacists when patients viewed it as a way to improve the care they receive.

Georgia↗
PubMed1980

Issues and opportunities in the regulation of home health care.

Recent federal legislation established a Certificate of Need (CON) process by which health care providers must receive state approval before building or renovating a facility, or adding a new service. Certainly, strict regulation of cost and quality of home health care is needed, but it is asserted that CON is an ineffective way of organizing the delivery of services and limiting costs, and furthermore, that CON is biased in favor of institutionally-based providers and maintenance of the status quo. The authors feel that vested interests have a history of trying to use earlier state CON regulations to control their turf, limit competition, and consequently stifle innovation. Home health care should be incorporated into national health planning goals and integrated into state and regional health plans. Such planning must precede CON regulations and should not be confused with it. Alternatives to CON can achieve quality service and moderate costs and include licensing of personnel, standards for provider accreditation, and utilization review. Planning for these alternatives should begin now to avoid fragmented expansion of home health care. Evidence suggests a comprehensive use of home health care as a cost-effective alternative for many levels of care given in hospitals and nursing homes.

Certificate of Need↗
PubMedDate not supplied

[A patient classification system for our primary care: the ambulatory care groups (ACGs)].

OBJECTIVES: The ambulatory care groups (ACGs) were developed at the Johns Hopkins University in 1987 and they differ from other systems because their longitudinal approach and its capability to describe the case-mix of a population of reference. This paper describes the ACGs and assess its potential application to spanish primary care (PC). METHODS: Observational study with the voluntary participation of 13 physicians (general practitioner and paediatrician) and nursing staff. During six months all diagnoses and interventions to a sample of attended patients were gathered. RESULTS: The first stage in grouping involves ascribing one of the 34 ambulatory diagnostic groups (ADGs) to each of the health problems attended. The second stage involves, after several intermediates steps, assigning one of the 51 ACGs to each patient. The total number of episodes was 7,559 (input), the number of patients (output) 2,467, the ICD codes with error 292, and the number of patients with ICD codes with error 278. With 5 ACGs we classify 44% of all the patients and with 10 ACGs, 64% of all them. Only two ACGs were empty. The article explores the potential applications of the system in spanish PC: for provider financing when a capitation payment component were introduced, utilization review and quality assurance when we compare several providers or populations, and research interested to link the process and its outcomes. CONCLUSIONS: Among the various patients classification system for grouping ambulatory care, the ambulatory care groups (ACGs) appear as the method with more potentialities to PC in Spain. The ACGs should be validated before been applied and its adaption to a more suitable PC classification of diagnoses would assists its extension.

Adult↗
PubMed2003

Changing the nature of physician referral relationships in the US: the impact of managed care.

Prior to the era of managed care in the US, health care delivery was managed by the professional activities of physicians. Managed care replaces management by profession with bureaucratic management structures and oversight, such as utilization review and gatekeeping (required referrals to specialty care). Practically, this means that physicians cannot use the professional relationships that typified practice under fee-for-service medicine, potentially changing not only what physicians do (e.g., order test or not, refer or not), but also how they do what they do. In this paper I look at just one of the changes brought about by managed care: contractual arrangements that require primary care providers to refer patients to a closed panel of specialist physicians. Through an in-depth case study of 45 primary care providers' in the USA who face restricted specialist panels for their managed care patients, but not for their fee-for-service patients, I investigate how the practice of referring is changed by this requirement. First, I use interview data to describe primary care providers general preferences for referral consultants, as well as their views of the referral process and potential barriers in it. Next I present data from all referrals over a four-week period to analyze the extent of referral relationships in actual referrals. Finally, I conclude by discussing some ways that managed care entities can facilitate rather than diminish referral relationships among physicians.

Fee-for-Service Plans↗
PubMed1998

Radiation therapy in the management of desmoid tumors.

PURPOSE: To evaluate the outcome of patients with extra-mesenteric desmoid tumors treated with radiation therapy, with or without surgery. METHODS AND MATERIALS: The outcome for 75 patients receiving radiation for desmoid tumor with or without complete gross resection between 1965 and 1994 was retrospectively reviewed utilizing univariate and multivariate statistical methods. RESULTS: With a median follow-up of 7.5 years, the overall freedom from relapse was 78% and 75% at 5 and 10 years, respectively. Of the total, 23 patients received radiation for gross disease because it was not resectable. Of these 23 patients, 7 sustained local recurrence, yielding a 31% actuarial relapse rate at 5 years. Radiation dose was the only significant determinant of disease control in this group. A dose of 50 Gy was associated with a 60% relapse rate, whereas higher doses yielded a 23% relapse rate (p < 0.05). The other 52 patients received radiation in conjunction with gross total resection of tumor. The 5- and 10-year relapse rates were 18% and 23%, respectively. No factor correlated significantly with disease outcome. There was no evidence that radiation doses exceeding 50 Gy improved outcome. Positive resection margins were not significantly deleterious in this group of irradiated patients. For all 75 patients, there was no evidence that radiation margins exceeding 5 cm beyond the tumor or surgical field improved local-regional control. Ultimately, 72 of the 75 patients were rendered disease-free, but 3 required extensive surgery (amputation, hemipelvectomy) to achieve this status. Significant radiation complications were seen in 13 patients. Radiation dose correlated with the incidence of complications. Doses of 56 Gy or less produced a 5% 15-year complication rate, compared to a 30% incidence with higher doses (p < 0.05). CONCLUSIONS: Radiation is an effective modality for desmoid tumors, either alone or as an adjuvant to resection. For patients with negative resection margins, postoperative radiation is not recommended. Patients with positive margins should almost always receive 50 Gy of postoperative radiation. Unresectable tumors should be irradiated to a dose of approximately 56 Gy, with a 75% expectation of local control.

Adolescent↗
PubMed1979

Comparative evaluation of the effect of a high yield criteria list upon skull radiography.

Based on results of studies using high yield criteria to determine the need for skull radiography, the Utilization Review Committee of the University Hospital (UH), University of Washington, Seattle implemented a policy encouraging use of the criteria in ordering skull radiology. The Bureau of Radiologic Health of the FDA supported a project comparing skull radiology use patterns at UH, with the high yield criteria policy, and Harborview Medical Center (HMC), without a policy. Results showed an increase of around 60% at HMC since the 1972--73 academic year. At UH, there was a decrease of 40% since the 1972--73 academic year. At HMC a medical record review showed only 51 positive reports that significantly contributed to patient care, about the same rate observed in 1967. At the UH, only nine positive reports significantly contributed to patient care, with 62% compliance with the high yield criteria. A current demonstration project under the auspices of the Washington State Professional Standards Review Organization and Bureau of Radiologic Health involves implementing the high yield criteria list at both HMC and UH. After three months, out of 6,003 patient visits, skull radiography was deemed necessary in 518 cases. Of this total 181 had high yield criteria checked. There were 37 positive reports out of these and 23 examinations that made a documented significant contribution to patient care. In the group without high yield criteria, 434 cases, there were 22 positive reports but no significant contribution to patient care documented after four weeks.

Craniocerebral Trauma↗
PubMed2003

Relevance of federal antitrust statutes to clinical practice.

With the advent of Medicare prospective payment systems, health care entities and physicians were forced to decrease expenses by sharing services and to increase revenue by attempting to jointly negotiate better reimbursement from third- party payers. Both activities have raised the specter of prosecution under antitrust laws that have been with us for more than a century but are poorly understood by practicing physicians. Recent monopolistic activities in the health care arena have prompted the Federal Trade Commission to file actions under specific acts of Congress, eg, the Sherman Anti-Trust Act, Clayton Act, Federal Trade Commission Act, Robinson-Patman Act, and Celler-Kefauver Act. Inasmuch as it is likely that specialties such as vascular surgery as a business will undergo substantial transformation, physicians need to be aware of the severe civil and criminal sanctions imposed if they are found guilty; fines that are several times actual damages; activities that raise antitrust issues including utilization review, medical staff privileges for competing specialties, participating provider agreements, and predatory pricing; and affirmative defenses and relief available in terms of specific exemptions. As health care providers react, innovate, and adjust to stay solvent, their business strategies will surely continue to be scrutinized for antitrust behavior by federal and state officials. The physician must have a basic understanding of the groundrules that govern any contemplated business strategy so that common pitfalls may be averted.

Antitrust Laws↗
PubMed1995

Implant standardization for total hip arthroplasty. An implant selection and a cost reduction program.

Total hip arthroplasty (THA) has been targeted by the United States federal government for cost control because of its high cost and rising incidence in the aging population. The hospital cost for THA during the 1980s was controlled by utilization review and a reduction in the volume of services delivered for each THA. The single largest increase in the cost of THA during the 1980s was the cost of hip implants. The Lahey Clinic Hip Implant Standardization Program was developed to provide objective guidelines for hip implant selection. These guidelines are based on the demands a patients is expected to place on his or her hip prosthesis. Because not every patient requires an expensive high-demand hip prosthesis, the standardization program also has the potential to reduce the hospital cost for hip implants without compromising patient care. Patients are assigned to four demand categories based on five objective criteria: age, weight, expected activity, general health, and bone stock. Selection of the prosthesis in each of the four demand categories is intended to match the implant's capacity with expected patient demand. The standardization program was retrospectively applied to 103 THAs performed during 1991. Analysis of variance demonstrated that patient variables and demand categories were statistically significant groupings. The cost of hip implants would have been reduced by 25.7% with the Lahey Clinic Hip Implant Standardization Program. A prospective outcome study is required to determine the long-term validity of this standardization program.

Activities of Daily Living↗
PubMed2004

Validation of diagnostic codes within medical services claims.

OBJECTIVES: Few studies have attempted to validate the diagnostic information contained within medical service claims data, and only a small proportion of these have attempted to do so using the medical chart as a gold standard. The goal of this study is to determine the sensitivity and specificity of medical services claims diagnoses for surveillance of 14 drug disease contraindications used in drug utilization review, the Charlson comorbidity index and the Johns Hopkins Adjusted Care Group Case-Mix profile (ADGs). STUDY DESIGN AND SETTING: Diagnoses were abstracted from the medical charts of 14,980 patients, and were used as the "gold standard," against which diagnoses obtained from the administrative database for the same patients were compared. RESULTS: Conditions associated with drug disease contraindications with the exception of hypertension and chronic obstructive pulmonary disease (COPD) showed a specificity of 90% or higher. Sensitivity of claims data was substantially lower, with glaucoma, hypertension, and diabetes being the most sensitive conditions at 76, 69, and 64%, respectively. Each of the 18 disease conditions contained in the Charlson comorbidity index showed high specificity, but sensitivity was more variable among conditions as well as by coding definitions. Although ADG specificity was also high, the vast majority of ADGs had sensitivities of less than 60%. CONCLUSION: The administrative data was found to have diagnoses and conditions that were highly specific but that vary greatly by condition in terms of sensitivity. To appropriately obtain diagnostic profiles, it is recommended that data pertaining to all physician billings be used.

Aged↗
PubMed2002

Gynecologic abnormalities in surgically treated women with stage II or III rectal cancer.

BACKGROUND: The objective of this article is to review the incidence and management of gynecologic abnormalities in women undergoing surgery for rectal cancer. STUDY DESIGN: We performed a retrospective chart review utilizing the Johns Hopkins Tumor Registry and Pathology database. Eighty-six female patients who underwent abdominal surgery between 1985 and 1996 for Stage II or Stage III rectal cancer were identified. Data gathered included: patient demographics, history, intraoperative findings and complications, cancer stage and histology, adjuvant treatments, and followup. Specific attention was focused on the diagnosis, management, and followup of concurrent gynecologic problems. RESULTS: At the time of surgery, nineteen women (22%) had previously undergone hysterectomy and bilateral salpingo-oophorectomy. Of the remaining 67 patients, 25 (37%) were found to have gynecologic abnormalities at the time of surgery, 15 (22%) underwent adnexectomy or hysterectomy or both. Forty-two women (63%) had normal internal genitalia. Of the 61 peri- and postmenopausal women, nine underwent bilateral oophorectomy for therapeutic reasons. No prophylactic oophorectomies were performed in any of the patients. CONCLUSION: Incidental pathologic findings necessitating gynecological procedures are common in patients undergoing surgery for rectal cancer. These findings are frequently suboptimally assessed and managed in the pre-, intra-, and postoperative periods. Colorectal surgeons operating on women with Stage II and III rectal cancer should be cognizant of the high likelihood of identifying incidental gynecologic pathology and be prepared for definitive management of the pathology. The utilization of prophylactic oophorectomy in postmenopausal women undergoing surgery for rectal cancer is currently not optimal; preoperative discussion should address this option.

Female↗
PubMed1998

A multipurpose model of radiology appropriateness criteria.

RATIONALE AND OBJECTIVES: Appropriateness criteria and practice guidelines are being developed in attempts to improve the cost-effectiveness of medical care. The authors sought to make a set of radiology appropriateness criteria usable for education, computer-based decision support, and utilization review. MODEL DEVELOPMENT: Sixty clinical conditions from the American College of Radiology's appropriateness criteria were selected. To make the information more suitable for automation, the names of the imaging procedures were standardized. Indexing terms were assigned to identify clinical conditions and to distinguish between each condition's variants. Semantic relationships between terms were defined. Information about the clinical conditions and variants, radiologic procedures, indexing terms, and relationships was encoded into a standardized language for document interchange. IMPLEMENTATION: The 1,956 rows in the appropriateness criteria tables for the 60 clinical conditions and their 212 variants were mapped into references to 163 distinct imaging procedures. The system's knowledge base included 301 indexing terms and 569 additional terms. CONCLUSION: Radiology appropriateness criteria can be indexed and encoded into a form that facilitates their use and interchange. The use of open, internationally accepted standards is an important step to make such knowledge portable and suitable for integration with evolving computer-based patient record systems.

Computing Methodologies↗
PubMed2002

Positron emission tomography and epilepsy.

PURPOSE: This review examines the current role of positron emission tomography (PET) in the investigation and management of patients with epilepsy. PROCEDURES: A literature review utilizing MEDLINE(R) and other sources was undertaken. For the comparison of the accuracy of PET with magnetic resonance imaging (MRI) for seizure focus localization, only publications since 1994 were examined. Individual patient data was tabulated to provide figures for seizure focus localization rates for different types of focal epilepsy and the prognostic value of PET findings for epilepsy surgery outcome. RESULTS: The majority of PET studies used 2-deoxy-2-[18F]fluoro-D-glucose (FDG). The epileptogenic sites typically show reduced FDG uptake (hypometabolism). In patients with intractable temporal lobe epilepsy (TLE), unilateral temporal lobe hypometabolism (UTH) corresponding to the seizure focus was seen in 86% of patients. In the same population, MRI demonstrated relevant abnormalities in 76%. UTH contralateral to the seizure focus was rarely seen (3%). Following temporal lobectomy, 86% of patients with ipsilateral UTH had a good outcome. When MRI was normal, UTH predicted a good outcome in 82%. Fifty percent with bitemporal hypometabolism had independent bilateral foci, and in those who proceeded to surgery only 50% had a good result. In extratemporal epilepsy, hypometabolism relevant to the focus was seen in 67% but, as in TLE, it was often more extensive than pathological abnormality. Recently evidence of a role for 11C-Flumazenil has emerged with reduced binding in the primary epileptogenic site. 11C-Flumazenil abnormalities appear more restricted to abnormal cortex and may be a better guide to the extent of resection required for surgical success. CONCLUSIONS: FDG-PET has a key role in the evaluation of patients with intractable partial epilepsy, particularly when surgery is a treatment option. Development and application of more specific biochemical probes may further improve the clinical value of PET for the understanding and treatment of epilepsy.

Journal Article↗
PubMed2000

Radiosurgery at the Royal Adelaide Hospital: the first 4 1/2 years' clinical experience.

Radiosurgery refers to the treatment of small lesions localized by stereotactic technology using highly focused radiation. This review utilizes prospectively gathered data from the Royal Adelaide Hospital Radiosurgery unit to summarize experience with the first 62 patients (65 lesions) treated between November 1993 and May 1998. This experience included acoustic neuromas (23 patients), arteriovenous malformations (18), brain metastases (12), meningiomas (6), and glomus tumour, subependymoma, dural arteriovenous fistula (1 each). Although follow up is relatively short, the outcome in terms of morbidity and tumour control is thus far comparable with results reported in the literature. Radiosurgery provides a viable alternative to neurosurgery and conventional external beam radiotherapy for several benign and malignant intracranial lesions.

Adolescent↗
PubMed2000

[Corroboration of concurrent assessment of inappropriate hospitalization with retrospective evaluation based on patient records].

BACKGROUND AND PURPOSE: Since the availability of a German adaptation of the "appropriateness Evaluation Protocol" (AEP) for hospital utilization review, physicians and health care managers were concerned about a potential overestimation of the extent of inappropriate hospital use in a retrospective assessment. The objective was to assess the agreement of concurrent and retrospective assessment of inappropriate hospital use. METHODS: The appropriateness of 42 admissions to surgical wards in a teaching hospital was tested concurrent to the admission. In 25 hospitalized patients the appropriateness of hospital days was assessed. Results were compared with the retrospective testing of the same patients after three months. RESULTS: Agreement between concurrent and retrospective assessment within the same reviewer was 86% of admissions (95% CI = 75%-96%) and 96% of hospital days (88%-100%). Kappa showed values of 0.85 and 0.78, which can be described as excellent. A comparison of two different reviewers, one testing concurrently, the other retrospectively showed agreements of 86% and 90%. The proportion of inappropriate days was the same in both designs. CONCLUSIONS: The results refute prior concerns that a retrospective assessment of the appropriateness of hospital use is impossible because in a retrospective design important clinical information would remain unconsidered or clinical information not yet available at that time would be used for the evaluation. The possibility of an incorrect assessment due to a retrospective design is within the variability inherent to the instrument. Despite the strong agreement, the small sample of surgical patient limits the generalizability of results.

Concurrent Review↗
PubMed1978

Concurrent quality assurance in hospital care. Report of a study by Private Initiative in PSRO.

To test the feasibility and effects of incorporating concurrent quality assurance (CQA) into the concurrent utilization reviews required by PSRO's, adherence to essential criteria of medical care and attainment of expected immediate outcomes were monitored prospectively in 5604 cases of seven conditions in 24 experimental and 26 control hospitals in five PSRO areas. CQA was not consistently associated with improved documentation in records, but was associated with slightly better adherence to treatment criteria in all five PSRO areas (P less than 0.03). Adherence to pooled documentation or treatment criteria was unrelated to outcomes. However, failure to adhere to disease-specific scientifically validated treatment criteria was associated with unsatisfactory outcomes in bacterial pneumonia (P less than 0.01) and acute myocardial infarction (P less than 0.02). CQA was professionally acceptable, technically feasible and compatible with PSRO reviews. Given adequate physician support, CQA can produce slightly greater adherence to treatment criteria. If the criteria are valid, adherence may lead to improved immediate outcomes in some diseases.

Adult↗