Diagnosis related groups and management.
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Costs and Cost Analysis↗
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Results for “Utilization Review”
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
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The fate of peer review: IFMC or elsewhere?
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Foundations↗
Relationship between chemical structure and allergenicity: aromatic amines.
This review utilizes current clinical and experimental contact sensitization data with aromatic amines to hypothesize on the relationship between chemical structure and allergenicity. The available data suggests: 1. A Primary amino group in the ring induces sensitizing properties; 2. aromatic amine allergenicity is related to basicity, resulting from the action of substituents in the ring; 3. electron donor substituents enhance whereas electron acceptor substituents attenuate the activity.
Allergens↗
The clinical pharmacist in a family practice residency program.
A project of interdisciplinary family medicine education was conducted in which a clinical pharmacist served as a drug therapy consultant-educator in a family practice residency program. The clinical pharmacist provided drug information, advised about drug therapy, taught in formal conferences, prepared and disseminated a drug information bulletin, made rounds with the physicians, provided drug blood level consultation, and conducted a drug utilization review project. The family physicians' attitudes about clinical pharmacy were assessed by interviews before and after the project and by a questionnaire administered after the project. The physicians and the pharmacist in this model were observed to have a greater understanding of the interdisciplinary team practice concept; and an active role for the clinical pharmacist as a teacher and consultant was reinforced.
Attitude of Health Personnel↗
The problem of cost containment in teaching hospitals: the Johns Hopkins experience.
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Concurrent Review↗
Catastrophic health insurance and cost containment: restructuring the current health insurance system.
Catastrophic health insurance may be necessary to curb rising health care costs in the United States. A major factor in this rise has been the current structure of the nation's health insurance system, which inadequately protects individuals with expensive illnesses, but encourages over-insurance for less expensive illnesses. This Note examines the current health insurance system, and analyzes its impact on health care costs for individuals and society. It evaluates several proposals to modify the structure of the current health insurance system, and recommends the adoption of a catastrophic health insurance plan based on an economic definition of catastrophe. Such a plan would decrease shallow coverage, and would use coinsurance and deductible rates keyed to the individual's income as means of increasing consumer cost consciousness without making necessary care unreasonably expensive. This Note also recommends that a catastrophic plan only cover treatment that has been determined medically necessary by utilization review, and that this review encourage outpatient rather than costly inpatient treatment.
Cost Control↗
Care management: providing a connecting link.
Care management monitors the variances of the entire patient population in a given area versus specific cases as demonstrated in case management. It includes CQI principles, variance analysis and regulatory standards. Care management serves as a conduit for continuing education, involves a multidisciplinary team approach, which involves the family and assists managed care and utilization review.
Case Management↗
Legal liability under managed care.
Market forces are driving the delivery of health care into managed care. New alignments among health care providers, payers, utilization reviewers and hospitals create new legal liability. Better-informed patients, concurrent credentialing by hospitals and payers, and new incentives to reduce hospital and physician-related costs have resulted in new federal legislation and agencies that reshape health care delivery and legal liability.
Hawaii↗
Workers' compensation introduction for physicians.
Workers' compensation is an important part of the employment system in this country, and its development was born out of necessity. In 1991, over 93 million employees were covered by workers' compensation statutes and laws for work related injuries and conditions. The costs over the past 20 years have increased at an overwhelming rate. These increases are being met by various cost containment strategies that are not omnipresent in all jurisdictions but instead, are being accepted and structured independently by each jurisdiction. Legislative changes are expected in the next few years to deter rising costs. The emerging patterns of cost containment are: limited initial provider choice, limited provider change, medical fee schedule, hospital payment regulation, utilization review, and bill review. The medical evaluation of impairment is a process that is not precise; however, impressive gains have arisen in this area through the use of the AMA Guides and DSM-IV.
Cost Control↗
Can experts agree when to hospitalize adolescents?
OBJECTIVE: Rates of psychiatric hospitalization and lengths of stay for adolescents have been a focus of recent controversy. With the advent of managed care, hospital systems and third-party payers are looking for ways to decide when hospitalization is indicated. The authors sought to determine whether experts could agree on the appropriateness of putative indicators for hospitalization of adolescents for conduct disorder or substance abuse. METHOD: Using a methodology developed at the Rand Corporation and previously applied to procedures in medicine and surgery, the authors developed a list of possible indications for hospitalization of adolescents with conduct disorder and/or substance abuse. A nine-member panel of experts in these areas, balanced by geography, academics/clinical practice, and whether the expert was in charge of a hospital unit, then rated the appropriateness of each indication twice under a modified Delphi procedure. RESULTS: Using prespecified definitions for agreement, after the initial rating the panel had low levels of disagreement (11%) and moderate levels of agreement (28%) on more than 1,900 possible indications for hospitalization. Despite an expanded number of indications, the panel reduced disagreement to less than 5% and increased agreement to more than 55% after the second round of ratings. CONCLUSIONS: The consensus achieved compared favorably with the results of similar panels judging the appropriateness of procedures in medicine and surgery. The methodology is applicable to studies of the appropriateness of pharmacological or psychotherapeutic interventions in both child and adult psychiatry. The results of such studies can form the basis for rational utilization review and treatment authorization decisions.
Adolescent↗
Health reform in Saskatchewan.
This paper describes the direction of health reform taking place in Saskatchewan. The rationale underlying the shift to a needs-driven, outcome-oriented, locally controlled health system is discussed. This shift is in concert with nationally recognized directions in improving health status, maintaining standards, ensuring a more cost-effective system, and providing a continuum of services characterized by a shift from institutional to community-based services, health-related public policy and health promotion. Included is a discussion of the process of change and some of the elements of the newly constituted delivery system, such as district boards, needs assessment, core services, and provincial components such as the Health Services Utilization Review Commission and the Provincial Health Council. Some implications for issues such as stroke prevention are noted.
Cerebrovascular Disorders↗
Appropriateness of hospital use by family physicians.
BACKGROUND: Reducing inappropriate hospital admissions could lead to lower total health care costs without compromising the quality of care. Research suggests that a sizeable portion of hospital admissions are inappropriate. Other studies indicate that family physicians use health care resources, including hospitalizations, less often than other primary care physicians. To gain additional insight into family physicians' decisions to admit patients, we performed an exploratory study using the Appropriateness Evaluation Protocol, a validated, clinically based utilization review instrument. METHODS: We assessed admissions by community-based and residency-based family physicians to a single university-affiliated hospital during calendar year 1988. A total of 905 patients were admitted to the hospital by family physicians during the study period. Of these, 889 records had complete data. Each was reviewed for appropriateness of admission. We calculated percentages of inappropriate admissions and used logistic regression to ascertain variables that were significant predictors of inappropriateness. RESULTS: Overall, 5.4 percent of admissions were categorized as inappropriate. Omitting obstetric cases, the rate was 10.5 percent. Inappropriate admissions did not cluster around a small number of diagnoses or diagnosis-related groups. Using logistic regression, we found that urgency of admission, patient insurance status, and residency-based physician admission versus community-based physician admission were significant predictors of inappropriate hospital use. Of the inappropriate admissions, 70 percent were so rated because diagnostic procedures or treatments could have been performed on an outpatient basis. CONCLUSIONS: In contrast with other studies for which physician specialty was not controlled, family physicians less frequently admitted patients inappropriately. Predictors of inappropriateness differed from those found in other studies. Changes in hospital systems, in addition to educational efforts directed toward individual physicians, hold promise as a strategy for reducing inappropriate hospital use.
Adult↗
Rational staffing of hospital nursing services by functional activity budgeting.
Nursing services are a costly item in the hospital budget, yet their justification is usually based on precedent and anecdote. Patient classification systems enable quantification of the nursing load on a daily basis. This methodology for determining the size of the nursing staff, however, has not gained widespread use because it tends to formalize existing staffing patterns. At the Johns Hopkins Hospital, physicians and nurses drew up a list of activities that should be performed for patients and that need to be considered in budgeting for nursing services. The largest and most variable components of the nursing workload are the tasks specified by physicians' orders and the nursing care plan. A computerized information system which communicates these orders can also be used to quantify these components of the nursing workload, since standard times to perform these tasks have been documented. The variability of these tasks from day to day and from patient to patient is the source of most of the problems of staffing. Other components of the workload, such as patient education, depend on the nursing program desired and must be added separately. Budget decisions can then be based upon the specific nursing functions which the hospital desires to perform. The technique of functional activity budgeting can also be used for the utilization review of physicians' use of nursing services.
Economics, Hospital↗
[Retrospective studies of resistance patterns of antibiotics in 1971 to 1974 (author's transl)].
A retrospective study was made of the resistance patterns of 16700 pathogenic bacterial strains from the region of Dordrecht (Netherlands) from the years 1971 through 1974. The importance of computer analysis for questions about resistance and antibiotic usage monitoring is supported. The practical importance of those analyses is the fact that antibiotics often have to be given without a known antibiogram. In those instances one must rely on historical data to guide the therapy and to compose a rational antibiotic utilization review. It should be interesting to repeat the study in other areas to establish an overall pattern for a country and to compare the findings on a country-by-country basis.
Anti-Bacterial Agents↗
Logical observation identifier names and codes (LOINC) database: a public use set of codes and names for electronic reporting of clinical laboratory test results.
Many laboratories use electronic message standards to transmit results to their clients. If all laboratories used the same "universal" set of test identifiers, electronic transmission of results would be greatly simplified. The Logical Observation Identifier Names and Codes (LOINC) database aims to be such a code system, covering at least 98% of the average laboratory's tests. The LOINC database should be of interest to hospitals, clinical laboratories, doctors' offices, state health departments, governmental healthcare providers, third-party payors, organizations involved in clinical trials, and quality assurance and utilization reviewers. The fifth release of the LOINC database, containing codes, names, and synonyms for approximately 6300 test observations, is now available on the Internet for public use. Here we describe the LOINC database, the methods used to produce it, and how it may be obtained.
Clinical Laboratory Information Systems↗
Patterns of decline among inpatient procedures.
This paper explores how the new financial incentives and organizational structures that prevail in the hospital industry have affected the mix of services provided by hospitals. Using data from the Agency for Health Care Policy and Research's Healthcare Cost and Utilization Project, the authors studied the 150 procedures that were most frequently performed on inpatients in 1980. They found that (a) 37 of the 150 procedures declined in use more than 40 percent by 1987, (b) patients that continued to receive one of the 37 procedures in 1987 on an inpatient basis tended to be more severely ill than in 1980, and (c) rates of decline were disproportionately large for Medicaid recipients. Three main factors have contributed to the decline in inpatient use of these procedures. Most important has been the shift from inpatient to outpatient settings, a result of new technologies and pressures from reimbursement mechanisms and utilization review policies. Some procedures have been replaced by less invasive, more effective approaches. Other procedures are now considered ineffective by the medical community and have been largely abandoned as a result.
Ambulatory Surgical Procedures↗
Undergraduate medical education in geriatrics: nursing home experience.
Preclinical medical students undertook an elective course in geriatrics which combined instruction in history taking, physical diagnosis, and problem-oriented assessment of elderly patients in a nursing home. A drug utilization review and specific drug therapy plans were formulated by pharmacy students. The project identified general problems susceptible to institutional as well as individual remedy. The students were led beyond their initial preoccupation with "physical complaints" to interest in pertinent psychological, social, and economic factors. A model of geriatric education for health science students can productively link the health science center and community nursing homes with benefits for the student, the patient, and the nursing home.
Aged↗
Panic disorder and depression: how can health care reform address behavioral disorders common in primary care?
The literature on panic disorder and depression illustrates the expense of not identifying and correctly treating behavioral disorders, including increased medical utilization, lost productivity, exacerbated comorbid conditions, and other indirect costs that exceed by at least three-fold the cost of treatment. This article discusses health care reform focused on person-based, rather than employer-based, health insurance: patient incentives to practice responsible utilization review; incentives for primary care physicians to identify and treat behavioral disorders; and facilitation of collaboration between primary care physicians and mental health consultants.
Anxiety↗