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PubMed1992

Utilization review. Emergency medicine implications.

The medical profession has made utilization review a priority in its efforts to limit health care expenditures. In emergency medicine this has ranged from initiatives to limit inappropriate emergency department visits to guidelines to limit emergency department testing and criteria to limit hospital admissions. The emergency department observation unit is an area in which the emergency physicians follow these practice guidelines without compromising patient care. The emergency department utilization review/quality assurance committee is a management tool by which emergency physicians monitor and implement these strategies for cost-effective patient care.

Clinical Laboratory Techniques↗
PubMed2004

Improving quality through identifying inappropriate care: the use of guideline-based utilization review protocols in the Washington State Workers' Compensation System.

Utilization review (UR) is widely instituted to ensure that medical treatment is clinically necessary and appropriate. UR programs have been criticized for their failure to promote quality and for relying on proprietary review criteria that are rarely subject to external, independent evaluation or validation. In fashioning its UR program for workers' compensation, the Washington State Department of Labor and Industries sought to address these shortcomings. Working collaboratively with the state medical association, the Department of Labor and Industries developed treatment guidelines and then used these guidelines to formulate review criteria for UR. From 1993 through 1998, 100,005 UR reviews were conducted, half of which used the guideline-based review criteria. We analyzed these reviews to examine the patterns of denied requests. The overall denial rate for the guideline-based reviews was 7.3%. The highest denial rates were for thoracic outlet syndrome surgery (19.1%) and lumbar fusion (17.7%). The use of guideline-based UR protocols may improve the effectiveness of UR as a tool to identify potentially inappropriate care.

Adult↗
PubMedDate not supplied

Utilization review and management: a primer.

URM, HIS, HMRI, DRG's, CMG'S, RIW's, etc. At the fall 1990 National Congress on Utilization Review and Management in Edmonton, Dennis Psutka referred to these as "alphabet soup". It is probable that many front line managers find many of these terms and abbreviations confusing, if not overwhelming. Intended as a primer, this manuscript will: define the key terms and concepts in utilization review and management; explain their interrelationships; and discuss why it is important for nurse managers to understand and use them, as the entire health care system struggles to achieve more with fewer resources.

Abbreviations as Topic↗
PubMedDate not supplied

Perceptions of utilization review nurses. "Nurses like us".

The purpose of this research was to describe the characteristics of nurses who perform telephonic care quality assessment, or utilization review, prior to, concurrent with, and after medical interventions and hospitalizations. It compares these nurses demographically to nurses employed in other settings, discusses the nurses' perceptions of the nature of their work, examines assertions that utilization review is a nursing activity, and documents the nurses' education and training for ethical decision-making. Implications for nursing care quality are discussed.

Adult↗
PubMed1979

Utilization review and resident education.

The reasons for psychiatric hospitalization are not always taught clearly and formally to psychiatric residents; screening criteria employed in utilization review can be a tool for helping residents gather data and make decisions about the admission or continued stay of patients. On the admitting and inpatient units of the Payne Whitney Psychiatric Clinic, residents use sets of criteria for admission and for continued stay, with accompanying guidelines and clinical examples, as part of their training. The authros outline principles used in developing the criteria, including the belief that they should be applicable independent of diagnosis. They suggest that in a teaching hospital screening criteria should be taken as standards, and that they should be developed as part of the educational program and only then introduced into utilization review.

Decision Making↗
PubMed2001

Ambulatory use of inhaled beta(2)-agonists for the treatment of asthma in Quebec : a population-based utilization review.

STUDY OBJECTIVES: To assess whether the utilization of inhaled short-acting beta(2)-agonists (ISAB) and inhaled long-acting beta(2)-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations. DESIGN: Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma. SETTING: Province of Quebec, Canada. PATIENTS: Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998. MEASUREMENTS: Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3). RESULTS: Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists. CONCLUSION: Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Administration, Inhalation↗
PubMedDate not supplied

Managing care: utilization review in action at two capitated medical groups.

Despite widespread concern about denials of coverage by managed care organizations, little empirical information exists on the profile and outcomes of utilization review decisions. This study examines the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review. We found much higher denial rates than those previously reported. Denials were particularly common for emergency care and durable medical equipment. Retrospective requests were nearly four times more likely than prospective requests were to be denied, and when prospective requests were denied, it was more likely because the service fell outside the scope of covered benefits than because it was not medically necessary.

California↗
PubMedDate not supplied

Differences characterize hospital utilization review, quality assurance activities.

Late in 1987, the American Academy of Medical Directors conducted a survey of its hospital-based members on staffing and other aspects of their utilization review and quality assurance functions. Responses were obtained from 130 of the 860 hospitals surveyed. The results show that, beyond the basics of hospital utilization review and quality assurance, hospitals are extremely diverse in their approaches to these functions.

Data Collection↗
PubMed2002

The liability of medical directors for utilization review decisions.

Managed Care Organizations (MCOs) have turned to numerous cost-containment measures to combat rising healthcare costs. One of the most common is the use of utilization review to ascertain whether a recommended mode of treatment is "medically necessary." When the medical director of an MCO determines that care recommended by a patient's treating physician is not medically necessary and not eligible for coverage (and, as a result, potentially unattainable due to cost), the stage is set for litigation. In such situations, medical directors may become potentially liable for disciplinary action by their state medical licensing board as well as lawsuits for malpractice or negligence. However, plaintiffs wishing to recover damages for improper determinations of this nature or state boards trying to discipline these physicians, face the hurdles of the preemptive force of ERISA, and state doctrines to the effect that corporations (and, derivatively, their medical directors) cannot practice medicine and therefore cannot be liable for malpractice. Conflicting decisions and opinions make it impossible at the present time to have a settled expectation regarding the potential liability of medical directors in this context, although the law appears to be moving toward the treatment of utilization review as medical decisionmaking; therefore, it appears likely that the activities of medical directors increasingly will face state oversight--including the imposition of common law liability in appropriate situations.

Decision Making, Organizational↗
PubMed1987

The effect of computerized utilization review on patterns of psychiatric inpatient care.

An interactive computerized utilization review system for psychiatric inpatient care was developed and tested on a 30-bed acute admission ward, where staff were trained in its use. The program permitted staff to review clinical decisions affecting length of stay and to receive immediate feedback on the cost and revenue for each case. The impact of the system was evaluated by comparing the length of stay of patients on the study unit with that of patients on a similar unit where the system was not in use, and also by comparing the length of stay for both units before and after the system was implemented. The findings showed that the length of stay on the study unit was significantly reduced after the system's implementation, and that it was well accepted by the staff. Six-month follow-up data showed no increase in symptomatology for the study patients compared with the control group.

Adult↗
PubMedDate not supplied

Drug utilization review using a Medicaid claims database.

A methodology for conducting drug utilization review (DUR) using Medicaid claims data is presented. The DUR allows for calculation of rates and costs of health care utilization among patients with established diagnoses and specific drug regimens; for comparison of results between competing drug therapies; for quantification of the percent market share of pharmaceutical products; and for projection of the duration of a given drug therapy. The strengths and limitations of using Medicaid data for DUR are discussed.

Databases, Factual↗
PubMed1987

Utilization review of psychiatric day hospitals in a Canadian urban region; II. Utilization patterns.

This article reports on a study which reviewed the utilization of six adult psychiatric day hospitals in a Canadian urban region. Part II of the study looks at the utilization patterns of these services through the examination of patients' demographics and clinical characteristics. The application of the study results to the planning of psychiatric services in the region is discussed.

Adult↗
PubMed1991

Potential liability in utilization review: the risk grows.

The use of cost containment measures in utilization review is a continuing topic of concern to physicians and payors. Focusing on a recent California case that dealt with this issue, this article discusses the potential liability of physicians and payors when such measures are used.

Cost Control↗
PubMed1975

Utilization review and suicide attempts. Exploring discrepancies between experts' criteria and clinical practice.

The discrepancies between experts' criteria for hospitalization of suicide attempters with actual clinical practice were explored to develop utilization review criteria which reflect current clinical thinking and which could form guidelines for the assessment of clinical care. Experts' criteria predicted that a hospitalized group of suicide attempters did not require hospitalization and that a nonhospitalized group of suicide attempters required hospitalization. Examination of the discrepancies between clinical practice and experts' criteria not only revealed that incorporation of clinical measures of depressive symptomatology could improve the experts' criteria for hospitalization but also showed that clinicians did not hospitalize a group of markedly symptomatic and socially impaired white suicide attempters. Clinician and patient factors that may have contributed to this decision making and the application of these findings for utilization review are discussed.

Adolescent↗
PubMed1977

Utilization review of the late adolescent patient in a mental health center: steps toward the development of criteria for the adequacy of assessment and treatment.

This study is concerned with an attempt to determine whether meaningful utilization review criteria could be productively generated by viewing a patient population from a developmental perspecitve. During a 2-year period, a multidisciplinary panel at Yale University sought to identify the sociodemographic, clinical, and administrative issues posed by late adolescents seeking treatment at the Connecticut Mental Health Center, New Haven. We sought to address the following questions: a) From what segment of the population were we drawing our adolescent patients? b) Who referred them for help? c) What kinds of problems led to referral? d) What were the diagnostic characteristics of the adolescent's evaluation? e) Under what conditions do adolescents terminate treatment? The charts of over 1222 adolescent patients were studied to help us answer these questions. Our investigation revealed that the adolescent patients seen at the Mental Health Center were sociodemographically and diagnostically heterogeneous. An increasingly large number of adolescents are referring themselves for evaluation and treatment, rather than being sent by schools, physicians, or social welfare agencies. The majority of patients seeking help come from blue collar or working class backgrounds mainly because of intrapsychic complaints of anxiety and depression. Upwardly mobile, they constitute a group who have completed their high school education, often live away from home, and are struggling with problems of defining an identity different from that of their family. Review of their charts indicated that significant sholastic, medical, and developmental information was frequently lacking or vaguely recorded. Our chart review also indicated that many clinicians did not ask their patients about symptoms relating to body functioning such as difficulties with sleeping, eating, or psychosomatic complaints. The study also discovered that it was difficult in the great majority of the charts reviewed to specify the adolescent's own perception of the difficulties which led them to seek help. Suggestions are then outlined for developing review criteria dealing with the emancipated adolescent, parental involvement in the treatment of the adolescent, treatment plans, and the termination of treatment. The comparative advantages of combining utilization review criteria from both a traditional "disease model" and a "developmental model" are discussed. The panel concluded that input from both perspectives is necessary in understanding the impact of a mental health delivery system upon adolescent patients, their family, and the community.

Adolescent↗
PubMed1992

The effects of utilization review on hospital use and expenditures: a covariance analysis.

Hospital utilization review (UR) has expanded rapidly in recent years and is now widely used by private payers as an approach to cost containment. This article reports estimates of the effects of UR on hospital utilization and medical expenditures based on a covariance estimation procedure. Claims data on 223 privately insured groups were analyzed covering a three-year period, 1984 through 1986. UR was associated with an approximate 12 percent decrease in admissions, a 14 percent decrease in hospital routine expenditures, and a 6 percent decrease in total medical expenditures. UR appears to reduce expenditures mainly by reducing admissions; hospital inpatient expenditures per admission were unaffected by the review activity. Analysis showed the effect of UR to have been greatest during the quarters immediately following implementation of the review activity. This finding underscores the need to analyze longitudinal data having sufficient time-series observations to obtain reliable estimates of long-term program impact. The analysis described here offers a computationally efficient alternative specification to the standard fixed-effects approach for analyzing pooled data, and is especially useful when the number of cross-section units is large.

Analysis of Variance↗
PubMed2004

Utilization review and managed health care liability.

This article explores the development of jurisprudence interpreting application of the Employee Retirement Income Security Act of 1974 to patient care denials by managed care. It identifies quality-of-care protections for patient care under present federal law. If an insurance company utilization review denies care based on patient-specific reasoning, then the patient may have recourse against the utilization review on the basis of a state law claim of malpractice grounded in medical decision-making by the insurance company.

Decision Making↗
PubMed1998

Effect of ambulatory utilization review on referrals from generalists to specialists.

We studied whether ambulatory utilization review (UR) alters how many patients internal medicine residents refer to sub-specialists, and whether the effect persists without reinforcement. We compared referral rates of residents from a firm that held UR meetings (intervention firm residents, n = 20) with those of residents from a firm that did not (control firm residents, n = 21). We then compared referral rates of 17 intervention firm residents while they were participating in UR with their rates after not participating for at least 4 weeks. Intervention firm residents submitted 30% fewer referrals than control firm residents (9% vs 13%, p = .05). However, the effect was short-lived; after 4 weeks without UR, intervention firm resident referral rates were similar to control firm referral rates.

Ambulatory Care↗