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PubMed1990

Services and charges by PPO physicians for PPO and indemnity patients. An episode of care comparison.

Physicians who participate in preferred provider organizations (PPOs) usually agree to various types of utilization review and sometimes discount their charges or agree to accept lower fees. This study was performed to determine whether they provided more or fewer services to their PPO patients than to their indemnity patients and whether the discounting resulted in lower expenditures for each episode of illness. In 1984, Metropolitan Life offered PPO coverage to Dade County (Florida) school board employees and dependents but only a standard indemnity plan to Dade County government employees and dependents. Episodes of care were examined for patients with chest pain, hypertension, joint pain, gastrointestinal or liver disorders, and lower back pain cared for by physicians who treated patients in both the PPO and indemnity employee groups. For PPO patients, charges per physician service were the same or lower, but total physician charges during an episode were higher. For services such as laboratory tests, diagnostic x-rays, and room and board, PPO and indemnity patients' charges were not significantly different.

Fees, Medical↗
PubMed1992

Methods for estimating days of hospitalization due to nosocomial infections.

While there is little agreement at the individual patient level of analysis, estimates of mean NI-attributed days of stay for the two methods were essentially the same. The lack of agreement at the individual patient level may reflect fundamental differences in the methods used to derive these estimates: incorporation of noninfected patient data versus exclusive reliance on data from infected patients; and, focus on length of stay rather than the actual care being received. The potential advantages of the AEP-based method include the following: 1) all patients with NI can be included in developing estimates; 2) estimates are based on the care provided rather than simple length of stay differences; 3) data on which to form the NI-day estimates are readily available in the medical record; 4) the AEP is a validated and commonly used utilization review instrument; 5) the AEP-based method has acceptable reliability; 6) this method is designed to provide individual and group estimates of NI-attributed days; 7) because every day of stay is reviewed, additional information is available, which results in greater precision of study of the development, diagnosis, and treatment of the NI relative to the other care that originally brought the patient into the hospital. The AEP-based method for estimating NI-days is a promising alternative to the historical cohort approach. Additional applications of this approach are encouraged to further assess its reliability,validity, and additional information yield.

Cohort Studies↗
PubMed1996

Physician practice style and rates of hospitalization for chronic medical conditions.

Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. The authors surveyed a random sample of 1,530 emergency physicians, general internists, and family and general practitioners in these areas, and measured clinical admission threshold by asking physicians whether they would hospitalize patients presented in 15 vignettes of graded severity. The authors measured social admission predisposition by asking how physicians' admission decisions would be influenced by social characteristics that increase patients' vulnerability to illness, including homelessness and drug use; 1,090 physicians responded (71%). There was significant variation across areas in both the clinical (P < 0.0001) and social (P < 0.001) admission scores. Variation in hospitalization rates correlated with physicians' clinical (r = .34, P = 0.03) and social (r = .36, P = 0.02) admission scores. However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.

Adult↗
PubMed1999

Managing health services: how the Population Health Information System (POPULIS) works for policymakers.

OBJECTIVES: 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 answering 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 is it 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 countries, utilization review within a single hospital, and longitudinal research on health reform. 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.

Community Health Planning↗
PubMed2006

An investigation of the effects of a healthcare provider network on costs and lost time in workers' compensation.

OBJECTIVE: The objective of this study was to evaluate the number of lost time days and cost of workers' compensation claims at a median claim duration (maturity) of 25 months for individuals injured between August 1, 2003, and July 31, 2004, who chose a statewide (Louisiana) network (Omnet Gold) of healthcare providers not subject to utilization review. METHODS: We identified and contrasted 176 lost time claims (143 closed) managed by Omnet Gold (OG) healthcare providers and 1464 lost time claims managed by healthcare providers not participating in OG. RESULTS: The average frequency of lost workdays for a closed OG claim was 53 days versus 99 days for a closed non-OG claim and the average cost of a closed OG claim was 12,554 dollars, whereas the average cost of a closed non-OG claim was 20,400 dollars. Both days lost from work and costs were significantly lower among claims managed by OG healthcare providers. This outcome was consistent with the findings of a previous study performed on the same claims in which a significant difference was demonstrated analyzing primarily open (unresolved) claims with a median claim duration of 6 months. The ability of OG healthcare providers to return a higher proportion of injured workers to work early and shorten claims durations were the major factors influencing these outcomes. CONCLUSIONS: In a state where claimants are permitted choice of medical provider, a network of healthcare providers can achieve superior lost time and cost outcomes than out of network healthcare providers.

Disability Evaluation↗
PubMed2005

Managed care and systems cost-effectiveness: treatment for depression.

OBJECTIVE: The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care. DATA SOURCES/STUDY SETTING: The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico. STUDY DESIGN: Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression. DATA COLLECTION/EXTRACTION METHODS: Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population. PRINCIPAL FINDINGS: System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness. CONCLUSION: Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.

Adolescent↗
PubMed2000

Managing patient trust in managed care.

Patient trust has been identified as an important element in the patient-physician relationship. However, common features of managed care, such as risk-sharing, utilization review, and limitations on benefits, may erode the traditionally high trust that patients have in their physicians. High trust is not always justified; rather, an optimal level of trust arises from the level of interdependence between patients and physicians. This analysis of the interrelationship between patient-physician trust and some of the key facets of managed care has important implications for managed care. A return to high levels of trust may be impracticable, and new strategies for balancing trust-building efforts by caregivers with checking mechanisms accessible to patients are recommended.

Confidentiality↗
PubMed1994

The compatibility of the retail setting with a patient-based practice model: reports from community pharmacists.

The patient counselling and prospective drug utilization review mandates of the Omnibus Budget Reconciliation Act of 1990 raise the question of how compatible the retail pharmacy setting in the United States is with a patient-based model of pharmacy practice. In order to investigate this question, a self-administered questionnaire was distributed by pharmacy students to a convenience sample of pharmacists with at least one year's experience in the community setting. The questionnaire asks respondents to recall two incidents: one that caused them to gain or retain a patient or that was for some reason a source of professional satisfaction, and one that may have caused the loss of a patient or that they would handle differently if faced with the situation or problem again. The respondents practice in pharmacies in and around a large midwestern city. Data analysis showed that respondents tend to identify patient-based activities when recalling appropriate behaviours and traditional or customer-based activities when recalling inappropriate behaviours or mistakes. Patient-based activities can sometimes result in the loss of business, but they can also result in patronage gains, especially when performed in conjunction with good customer service. In summary, these pharmacists do implement a patient-based model in some situations. The patient-based and customer-based models can be complementary in that the patient can benefit from the services of an expert health professional while simultaneously being treated with the respect and 'customer knows best' attitudes indicative of the retail setting.

Attitude of Health Personnel↗
PubMed1993

Improving the quality and ease of tracking invasive procedures.

Documentation of the decision-making process leading up to an outcome of procedures is essential for assessing quality of patient care, supporting reimbursement, determination of appropriate utilization, and discernment of practitioner competence. Currently, doctors document interventions conducted outside the operating room in narratives within the daily progress notes. The free-form narrative typically includes the practitioner directly involved, procedure performed, technique used and outcomes. While hospitals encourage conformity to these documentation standards, the quality and content of the narratives vary greatly by practitioner, frequently leaving significant information missing. Therefore, to improve both quality of documentation in procedure notes and ease of monitoring non-operating room procedures, we developed a multicopy standardized procedure note. The form contains lines for recording the type, location, indication, anaesthesia, findings, and complications of the procedure, plus the persons performing, supervising and undergoing the procedure. Practitioners complete the multicopy note instead of the usual narrative note. We encode all the information from the standardized note into a data base that accumulates information on all procedures done throughout the hospital. The data base is used to generate summary reports to provide feedback to residents, residency directors and practitioners on procedural proficiency. The major advantage of this system is that it simultaneously improves the quality of documentation and ease of tracking non-operating room procedures at our hospitals. In addition, the system collects the information needed for reimbursement coding, hospital quality assurance and utilization review, and practitioner and resident credentialling purposes.

Clinical Competence↗
PubMed1996

Social support and knowledge level of the older adult homebound person with diabetes.

The purpose of this study was to continue research related to the identification of social support systems for an older adult homebound population of people who have diabetes compared to a control group of elder home care clients without diabetes, their knowledge level, and the significance of home health care intervention in these support networks. A sample of 11 older adult homebound people with diabetes and 11 older adult home care controls without diabetes from two home care agencies in Connecticut were used for this pilot study. A large sample was projected, but home-visiting scheduling difficulties arose. Eighty-two percent of both groups had adequate support systems. There was some difficulty with interpretation of the Homebound Diabetes Knowledge Level Questionnaire and further refinement is needed, especially in relationship to non-insulin-dependent diabetes mellitus client responses. Results from chart review, utilizing the Diabetes Clinical Indicator Tool, yielded a 59%-66% rate of the criteria met in the four categories outlined. It is evident that social support makes a significant contribution to the physical and psychological well-being of the home care elder, but further study is needed to examine the relationship between an individual's personal and professional network of support in this setting.

Aged↗
PubMed1978

Quality assurance for alcoholism treatment.

Mechanisms that seek assurance of quality care at reasonable cost include utilization review, accreditation, certification, licensure, and patient care audit. Within the social rehabilitative field, it is probably safe to say that only alcoholism has developed and implemented what might be considered the majority of the significant elements of a quality assurance program.

Accreditation↗
PubMed1992

Geriatric care approaches in health maintenance organizations.

The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.

Geriatric Assessment↗
PubMed1979

Selection criteria for family therapy.

The patient selection criteria for most modalities of psychotherapy have not yet been clearly articulated. This paper presents a decision-tree model outlining the factors that incline a clinician to perform a family evaluation, then to decide upon family treatment instead of another form of therapy, and finally to settle upon the particular duration and intensity of family treatment. We have compiled screening criteria, based on research and clinical opinion, to be applied in the utilization review of the decisions made at each of these steps. This method can be used to evaluate the appropriateness of care and render decision-making explicit and accountable; it may also have considerable value in training and research.

Crisis Intervention↗
PubMedDate not supplied

The clinical nurse specialist as brief psychotherapist.

As managed care continues to flourish, the psychiatric clinical nurse specialist may function as a case manager for a managed care company or as a utilization review nurse for a hospital, community provider, or administrator. Stressing the strengths of the psychiatric clinical nurse specialist as brief therapist, the author reviews elements of the brief treatment model, including assessment, focus of treatment, knowledge of community resources, patient education, group skills, crisis intervention, and treatment planning.

Humans↗
PubMed1993

Adequate access to posthospital home health services: differences between urban and rural areas.

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.

Aged↗
PubMedDate not supplied

Exploring the utility of automated drug alerts in home healthcare.

Computerized drug utilization review (DUR) can potentially reduce adverse drug events. We examined automated DUR for home healthcare patients with diabetes or hypertension. Sixty-eight percent of diabetes patients and 50.7% of hypertension patients triggered severe, moderate, or duplicative alerts. Among diabetes patients, 74.3% of duplicative alerts were trivial or inappropriate, compared with 3.9% among hypertension patients. Experts judged that 40.5% of high-risk diabetes patients and 53.6% of hypertension patients had alerts requiring nurse follow-up. Adequate follow-up was significantly lower for the former. The relationship between inappropriate alerts and poorer follow-up reinforces the need for more specific alert systems to focus clinicians' attention on clinically important alerts.

Adverse Drug Reaction Reporting Systems↗
PubMed2006

Advanced drug delivery systems that target the vascular endothelium.

Targeted drug delivery to endothelial cells lining the vascular lumen will provide effective, precise and safe therapeutic interventions for treatment of diverse disease conditions. Rational design of such drug delivery systems (DDS) includes the following intertwined tasks: 1) selection of proper target determinants on endothelial surfaces, such as cell adhesion molecules, ectopeptidases, or caveolar antigens; 2) production of affinity ligands useful for targeting, such as affinity peptides, antibodies, or their fragments; 3) selection and adopting of suitable delivery vehicles (such as liposomes or polymer nanocarriers); and 4) formulation of DDS with optimal targeting and therapeutic features. Important therapeutic features of DDS include: 1) sufficient targeting effectiveness, circulation time, and safety (i.e., lack of systemic and local adverse effects); 2) precise subcellular localization of drugs targeted to endothelial cells; and 3) adequate amplitude, kinetics, and duration of effects. This review utilizes examples of DDS-mediated interventions in vascular inflammation, oxidative stress, and thrombosis and analyzes them in an attempt to create design parameters that best regulate the pharmacological and therapeutic features of DDS that target endothelial cells.

Biological Transport↗
PubMed1981

Electrical stimulation of the spinal cord and peripheral nerves for pain control. A 10-year experience.

Patients who underwent implantation of dorsal column stimulators from 1970 to 1973 were reviewed 7-10 years following stimulation. The number who achieved satisfactory pain relief was not significant. The criteria for selecting these patients were reviewed utilizing those now used in 1980. 50% of the patients originally selected would now be rejected for psychological or drug-related reasons. This long-term evaluation indicates no benefit to the patients treated with spinal cord stimulation. However, it appears that psychological factors were the most important reasons for failure. A smaller group of patients studied for 3-5 years following implantation of epidural spinal cord stimulators achieved a 70% pain control rate. Selection factors that explain these differences are discussed.

Brachial Plexus↗