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PubMed1993

Provider selection standards as a quality indicator.

There are many lessons that PPOs and their clients have learned during the past decade. Data are essential. Few claims administrators have invested the capital or resources to capture other than minimal data--many capturing only the elements required to produce a reimbursement check. The more extensive the data collection, the greater the potential for improving quality. The best way to assure the delivery of high quality health care is to implement a rigorous selection process, preferably prior to granting membership. In an ideal world, selection can lead to the elimination of many aspects of managed care so that the focus can be placed on physicians whose practice style yields lower quality and higher costs. The ability to implement CQI in a PPO is limited only by the ingenuity of the reviewer and the data. Most importantly, the past decade has proven the basic tenet of managed care--quality health care is cost-effective health care.

Contract Services↗
PubMedDate not supplied

A retrospective review of performance and utility of routine clinical pelvimetry.

BACKGROUND AND OBJECTIVES: Some authorities have questioned the utility of performing clinical pelvimetry as part of routine prenatal care. This study determined the frequency with which clinical pelvimetry is still performed at two military hospitals and whether the results of pelvimetry influence the management of labor and delivery. METHODS: We conducted a retrospective review of prenatal records at two military hospitals. One was an overseas hospital, and one was a family medicine teaching hospital in the United States. The records of 660 pregnant women were reviewed to identify documentation that pelvimetry was performed during prenatal care and whether there was evidence that the physician managing labor and delivery altered management based on pelvimetry results. RESULTS: Seventy percent (461) of the 660 records reviewed had all pelvimetry measurements documented as normal, or the provider had written "good for TOL (trial of labor)," "proven to XX pounds," or similar annotation that pelvimetry was normal. Nine percent (58 records) had no documentation of pelvimetry (pelvimetry section left blank). The remaining 21% (141 charts) had at least one pelvimetry measurement listed as abnormal on the initial prenatal exam. No admission note, progress note, or operative note recorded during labor and delivery made reference to clinical pelvimetry results. No abnormal pelvimetry result was referenced in follow-up visits or appeared to make any difference in mode of delivery or treatment in labor. Two women (one at each institution) had initial visit notes indicating the need to consider radiographic pelvimetry based on the results of clinical exam, but this test was not done in either case, and both women delivered vaginally. CONCLUSIONS: Our study indicates that clinical pelvimetry does not change management of pregnant patients. Current practice is to allow all women a trial of labor regardless of pelvimetry results. This makes the routine performance and recording of clinical pelvimetry a waste of time, a potential liability, and an unnecessary discomfort for patients.

Female↗
PubMed2004

A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation.

The atypical antipsychotics risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole have become first-line treatment for schizophrenia because they reduce the positive symptoms of psychosis but do not have a high incidence of extrapyramidal symptoms. However, these agents, like other antipsychotics, may take as long as 16 or more weeks to produce a response, and even with prolonged treatment are unlikely to evoke responses greater than 50% improvement in symptoms. This has led to the experimental use of high atypical antipsychotic doses, antipsychotic polypharmacy, and augmentation with other psychotropic drugs, all of which occur commonly in clinical practice. This article reviews the current evidence for these increasingly common means of treating schizophrenia and psychosis, with particular emphasis on polypharmacy and augmentation. To date, there are only two controlled studies of antipsychotic polypharmacy involving an atypical antipsychotic; the rest of the data are uncontrolled trials and case reports that describe a mixture of positive and negative findings. One multicenter, double-blind trial shows a faster onset of action when divalproex is added to risperidone or olanzapine than with antipsychotic monotherapy. A small double-blind study demonstrates efficacy when lamotrigine is added to clozapine. The rest of the data on augmentation with anticonvulsants are uncontrolled, and most report adverse effects. With the exception of divalproex, there are currently no compelling data to justify the use of antipsychotic polypharmacy or augmentation. Existing evidence suggests that the best treatments for schizophrenia and psychosis may be long-term trials of a sequence of atypical antipsychotic monotherapies at therapeutic doses.

Acetates↗
PubMed1997

Gastrointestinal illness in managed care: healthcare utilization and costs.

Identification of inefficiencies is a first step to improving the quality of gastrointestinal (GI) care at the most reasonable cost. This analysis used administrative data to examine the healthcare utilization and associated costs of the management of GI illnesses in a 2.5 million-member private managed care plan containing many benefit designs. An overall incidence of 10% was found for GI conditions, with a preponderance in adults (patients older than 40 years) and women. The most frequently occurring conditions were abdominal pain, nonulcer peptic diseases, lower GI tract diseases, and other GI tract problems. These conditions, along with gallbladder/biliary tract disease, were also the most costly. Claims submitted for care during GI episodes averaged $17 per member per month. Increasing severity of condition was associated with substantial increases in utilization and costs (except for medication use). For most GI conditions, approximately 40% of charges were for professional services (procedures, tests, and visits) and 40% of charges were for facility admissions. The prescription utilization analysis indicated areas where utilization patterns may not match accepted guidelines, such as the low use of anti-Helicobacter pylori therapy, the possible concomitant use of nonsteroidal anti-inflammatory drugs in patients with upper GI diseases, and the use of narcotics in treating patients with lower GI disease and abdominal pain. Also, there was no clear relationship between medication utilization and disease severity. Thus, this analysis indicated that GI disease is a significant economic burden to managed care, and identified usage patterns that potentially could be modified to improve quality of care.

Adult↗
PubMed2006

Pharmacy fill patterns in young urban children with persistent asthma.

BACKGROUND: Medication adherence impacts healthcare utilization. Pharmacy records are useful to establish fill patterns. OBJECTIVE: Use pharmacy records to establish medication patterns fill patterns for comparison to healthcare utilization. Methods. Pharmacy records of 175 children with persistent asthma were collected and compared to healthcare utilization. RESULTS: Majority of subjects had significant healthcare utilization, low numbers of rescue medications, and poor controller medication fill rates. Those with more rescue medications had more healthcare utilization and more controller medications. CONCLUSIONS: Pharmacy fill patterns demonstrate few rescue and/or controller medication fills. Those with more rescue medications reported increased healthcare utilization despite controller medications.

Administration, Oral↗
PubMed2001

Efficacy theory and its utility in arthritis rehabilitation: review and recommendations.

PURPOSE: Self-efficacy, a cognitive construct implicating one's self-perception about one's performance ability, has been found to be a significant predictor of psychological well-being, adherence to prescribed treatments, and pain coping mechanisms of persons with arthritis. Heightened self-efficacy may also ameliorate arthritis-related symptoms of fatigue and depression, and preserve function and prolong physical well-being. METHODS: To elaborate upon the utility of self-efficacy enhancing strategies as this pertains to ameliorating arthritis-related disability, this paper examined the related literature on this topic and detailed the outcomes and nature of those self-efficacy enhancing strategies that have been incorporated into arthritis treatment regimens. RESULTS: Despite limitations in the prevailing database, results indicated: (1) self-efficacy is potentially a potent predictor of the overall health status of the person with arthritis; and (2) carefully designed self-efficacy enhancing strategies are likely to impact favourably upon the magnitude of the disability experienced by individuals with arthritis. CONCLUSIONS: In relation to maximizing the therapeutic outcomes for disabling arthritis, the concept of self-efficacy is very worthy of the clinical practitioners and the clinical researchers attention.

Arthritis↗
PubMed1979

Utilization of hospital services in the Individual Practice Association on Guam: a comparative analysis.

The HMO Act of 1973 gives impetus on a nationwide scale to the development of health care delivery systems capable of providing or arranging for comprehensive health services for our nation's consumers. However, while the organizational mode of the group-practice model HMO is well defined and tested, there has not been a similar "track record" established for the individual practice HMO. In this study, the author compares the utilization of hospital beds in two operating programs: an individual practice and a group-practice HMO, serving employees of the Government of Guam, U.S.A. Substantial differences in utilization between the two systems are observed over a 12-month period. With the focus on developing the IPA to meet the objectives for which it is intended, it is suggested that organizational structure, provider incentives, and how utilization controls were employed account for the discrepancy.

Cost Control↗
PubMed1995

The effect of managed care on the treatment outcome of substance use disorders.

This study examined the effect of managed care and other reimbursement mechanisms on the outcome of substance abuse treatment at a single treatment facility. A retrospective review of 1594 patient records yielded treatment utilization, diagnostic, and demographic data. Recidivism rates for intensive managed care, traditional managed care, private pay, and state-funded groups of patients were compared. Results showed that, contrary to expectations, recidivism rates were not different for managed vs nonmanaged care patients. In addition, recidivist patients had significantly more ICD-9 diagnoses than nonrecidivist patients. A discussion of future research suggests that other outcome measures need to be examined in addition to recidivism rate, such as psychosocial functioning following treatment and indicator(s) of severity of illness, to better determine the effect of managed care and other reimbursement mechanisms on treatment outcome.

Adult↗
PubMedDate not supplied

Underuse of procedures for diagnosing osteoporosis and of therapies for osteoporosis in older nursing home residents.

OBJECTIVE: To investigate the prevalence of osteoporosis, the prevalence of utilization of bone mineral density (BMD) measurements for diagnosis of osteoporosis, and prevalence of use of calcium and vitamin D supplements and other antiresorptive therapies for treatment of osteoporosis in postmenopausal women in an academic nursing home. METHODS: The charts of all women aged 56 years and older residing in an academic nursing home were analyzed by one of the authors for the prevalence of osteoporosis, the prevalence of use of BMD measurements to diagnose osteoporosis, and the prevalence of use of calcium and vitamin D supplements and other antiresorptive therapies for treatment of osteoporosis. RESULTS: Of 136 postmenopausal women, mean age 79 +/- 10 years, 66 (49%) had measurements of BMD. Of these 66 women, 31 (47%) had osteoporosis, 21 (32%) had osteopenia, and 14 (21%) had normal BMD. Elemental calcium carbonate 1500 mg daily was prescribed to 17 of 31 women (55%) with osteoporosis, to 12 of 21 women (57%) with osteopenia, to 2 of 14 women (14%) with normal BMD, and to 27 of 70 women (39%) with no BMD obtained. Any dose of calcium was prescribed to 78 of 136 elderly women (58%). Vitamin D supplements were prescribed to 13 of 31 women (42%) with osteoporosis, to 9 of 21 women (43%) with osteopenia, to 2 of 14 women (14%) with normal BMD, and to 20 of 70 women (29%) with no BMD obtained. Vitamin D supplements were prescribed to 44 of 136 elderly women (32%). Biphosphonates were prescribed to 19 of 31 women (61%) with osteoporosis. Of 20 women on medications that increased the risk of osteoporosis, 6 (30%) had BMD measured. Nine of these 20 women (45%) were on calcium supplements. CONCLUSIONS: Older postmenopausal women in an academic nursing home have a high prevalence of osteoporosis and osteopenia, a low prevalence of measurement of BMD, and underuse of calcium, vitamin D supplements, and other antiresorptive therapies for treatment of osteoporosis.

Absorptiometry, Photon↗
PubMed2001

Risperidone: review of its therapeutic utility in depression.

There is extensive evidence to implicate dysregulation of noradrenergic, serotonergic, and dopaminergic neurotransmission in the pathophysiology of mood disorders. The receptor profile for risperidone, an atypical antipsychotic with demonstrated efficacy in schizophrenia, is consistent with possible antidepressant activity. Specifically, risperidone is a potent antagonist of central 5-HT2A receptors, addressing symptoms such as insomnia, agitation, and weight loss and may indirectly enhance 5-HT1A-mediated neurotransmission. A search of the worldwide medical literature published through December 2000 revealed 24 publications pertinent to the clinical use of risperidone in the treatment of patients with depressive symptomatology. In schizophrenia, in which depression is a common comorbid condition, the results of eight randomized, blinded, and controlled trials consistently demonstrated that treatment with risperidone significantly reduced scores on various measures of depressive symptoms. Moreover, these effects were distinct from improvements in negative and positive symptoms. Antidepressant effects also were observed in two large meta-analyses of trials in patients with schizophrenia or schizoaffective disorder. Observations from uncontrolled studies and case reports of risperidone therapy of other psychiatric disorders were similarly suggestive of antidepressant activity. Collectively, the evidence we present in this review indicates that risperidone's therapeutic benefits in psychiatric medicine extend beyond potent and effective antipsychotic activity and may include effectiveness in treating depression and related affective disorders. Systematic studies are now needed to evaluate the utility of concomitant therapy with an atypical antipsychotic in psychotic, bipolar, and treatment-resistant depressive syndromes.

Animals↗
PubMed1990

Effect of acceptance or rejection on the author's evaluation of peer review of medical manuscripts.

To determine whether authors of rejected manuscripts would evaluate the editorial review process less favorably than would authors of manuscripts accepted for publication, a questionnaire was sent to solicit evaluations of the quality of the reviews that had led to the rejection or acceptance of manuscripts submitted to the Journal of Pediatrics. Similar evaluations of the editor's letter were also sought. Authors were more likely to respond to the questionnaire if their manuscripts had been accepted and were more likely to complete the questionnaire thoroughly. Authors of accepted manuscripts evaluated the editor's communication more favorably than did the authors of manuscripts not accepted for publication, but the evaluations of the reviews were not significantly different. Most authors utilized the reviews to modify their manuscripts before submitting them to another journal.

Authorship↗
PubMed1996

Utilization of antidiabetic drugs in Hong Kong: relation to the common occurrence of antidiabetic drug-induced hypoglycemia amongst acute medical admissions and the relative prevalence of NIDDM.

Antidiabetic drug-induced hypoglycemia as a cause of acute medical admissions is more common in Hong Kong (1.7%) than in other countries (0.1-0.5%). To determine if this higher incidence may be related to the frequent use of some sulphonylureas, we have studied the overall prescribing patterns in the public sector in 1994 by reviewing the utilization of antidiabetic drugs in the general out-patient/general practice clinics (GOPD) and Hospital Authority public hospitals and affiliated specialist clinics (HA). The vast majority of patients (90.5%) receiving antidiabetic treatment were taking sulphonylureas and/or metformin, confirming that diabetes mellitus in Hong Kong is predominantly of the noninsulin-dependent type. The GOPD and the HA each accounted for approximately half of the sulphonylureas (55% vs 45%) and metformin (43% vs 57%) prescribed. Glibenclamide (84.9% vs 79.1%, 83.7% overall) and gliclazide (12.8% vs 16.6%, 14.5% overall) were the 2 most frequently used sulphonylureas. Only 9.5% of patients on antidiabetic drugs were receiving insulin and 92% of this was prescribed by the HA. For comparison, Singapore has a similar prevalence of diabetes mellitus but a much lower incidence of antidiabetic drug-induced hypoglycemia amongst acute medical admissions (0.5%). Tolbutamide was the most frequently used there sulphonylurea (66.6-72.2%) with glibenclamide only contributing 20.8-28.6%. Thus, the predominant use of glibenclamide in Hong Kong may contribute to the high incidence of antidiabetic drug-induced hypoglycemia amongst acute medical admissions.

Acute Disease↗
PubMedDate not supplied

Antibiotic utilization monitoring--study and review in a Canadian teaching hospital.

Patients receiving gentamicin, cephalosporins and penicillinase-resistant penicillins were monitored by pharmacists in a 536-bed university hospital. Of the 217 cases monitored 56% were considered to be rational therapy, 34% were irrational therapy and 10% were questionable. The guidelines used for evaluation of cases were The Audits of Antimicrobial Usage. Guidelines for Peer Review, Kunin and Efron 1977. Treatment was the indication for antibiotic use for the remaining 32% of cases. Sixty-seven per cent of prophylactic therapy was considered to be irrational.

Anti-Bacterial Agents↗
PubMed1993

Drug therapy during cardiac arrest in two hospitals.

The results of a study evaluating the appropriateness of drug and defibrillation therapy given during cardiac arrest at two hospitals are reported. A retrospective study was performed to evaluate and compare the appropriateness of therapy given during adult cardiac arrest at a large teaching hospital (hospital 1) and at a smaller nonteaching hospital (hospital 2) as measured by conformance to advanced cardiac life support (ACLS) guidelines and by less stringent alternative criteria based on published data and clinical judgment. Patients included in the study were older than 18 years and had experienced at least one of five types of cardiac arrest: ventricular fibrillation, asystole, ventricular tachycardia, electromechanical dissociation, or bradycardia. The type of drug administered, the drug dosage, and the timing of dosages were evaluated, as were the timing of defibrillation attempts and the energy used for such attempts. Treatment decisions were considered inappropriate if they did not conform to standard (ACLS) or alternative criteria. In hospital 1, there were 1137 assessable decisions recorded for 75 cardiac arrests; of these, 205 (18%) were inappropriate according to standard criteria, and 96 (8.4%) were inappropriate according to alternative criteria. In hospital 2, there were 827 assessable decisions recorded for 57 cardiac arrests; of these, 173 (21%) were inappropriate according to standard criteria, and 98 (11.2%) were inappropriate according to alternative criteria. Inappropriate therapy during cardiac arrest occurred with a similar frequency in a large teaching hospital and in a smaller, nonteaching hospital. The number of inappropriate treatments was smaller when more liberal standards of therapy were used.

Algorithms↗