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At least 19 recordsLinked to original sources
PubMed1979

The relationship between diagnostic information available at admission and discharge for patients in one PSRO setting: implications for concurrent review.

Professional Standards Review Organization (PSRO) operating guidelines recommend the use of Professional Activity Study (PAS) length of stay norms for conducting concurrent review. These norms, determined by aggregating discharge abstracts from PAS hospitals in the same United States census region, are assigned to patients based only on information known at admission. This study investigated the relationship between patient information available at admission and the information available at discharge in light of its effects on the concurrent review process. Analyzing 52,210 patient records from 68 hospitals in one PSRO setting, it was found that changes in patients' primary diagnosis resulted in changes in their PAS diagnostic category for 41.3 per cent of the patients. A change in PAS diagnostic caetgory after the assignment of the review norm resulted in missed and unnecessary reviews as well as early and late reviews. These findings indicate that there are serious operational problems with the current method of performing concurrent review.

Commission on Professional and Hospital Activities↗
PubMed1979

Reassessing the early effect of concurrent review on length of stay: Illinois, 1971--72.

The Hospital Admission and Surveillance Program (HASP) was a pre-PSRO program in Illinois. Established in February 1972, its objective was to reduce the cost of care given to Medicaid beneficiaries in that state. HASP approved length of stay (L.O.S.) on a prospective only basis, so that all Medicaid patients were reported promptly on admission. During 1972, the Illinois Medicaid program was rapidly expanding in patient volume, but not in scope of services. This study compares patients admitted to 46 hospitals in Illinois before and after the establishment of HASP. To adjust for changes in case mix between the two periods, each patient was matched for age, diagnosis and illness severity with patients in an appropriate comparison group. The complex process of matching raised the likelihood that changes in L.O.S. were caused by HASP's activities and not by other factors. L.O.S. fell significantly more for Medicaid than for non-Medicaid patients. In addition, the mix of diagnoses changed more markedly for Medicaid than non-Medicaid patients, emphasizing the need for case mix adjustments in this before-and-after study. Some findings suggest that the "post-HASP" admissions had the greater need for hospital care; this trend affected both Medicaid and non-Medicaid patients, however, The combined evidence suggests that concurrent review, as implemented by HASP, helped shorten L.O.S. in 1972. Whether quality of care changed was not studied.

Age Factors↗
PubMed1992

New methods for evaluating utilization management programs.

Blue Cross and Blue Shield of Massachusetts, Inc (BCBS), has developed two new methods for measuring the effect of utilization management (UM) in reducing unnecessary hospital use. The "program component" method measures the separate effect of preadmission review, concurrent review, and discharge planning. The "savable days" method produces a composite measure of the effectiveness of the program as a whole. The use of these two methods is illustrated with five years of utilization review data from the BCBS nongroup insurance product. The results can be used by operations managers and policymakers to measure the performance of individual UM components and the program as a whole, to establish goals and monitor program performance, to modify the program in response to changing utilization patterns, to assist in developing premiums, to establish risk-sharing agreements with employers or providers, and to demonstrate the effectiveness of the program for use in marketing.

Blue Cross Blue Shield Insurance Plans↗
PubMed1991

The impact of Blue Cross and Blue Shield Plan utilization management programs, 1980-1988.

This study evaluates the aggregate and temporal impact seven Blue Cross and Blue Shield Plan utilization management (UM) programs have on hospital utilization and payments over a nine-year period, 1980 through 1988. The impact of these programs is determined using a statistical model that controls for variations in organizational characteristics of 56 Blue Cross and Blue Shield Plans, the health care market of the individual Plan, and several state and federal health care regulations. The statistical results indicate that over the entire period 1980 to 1988, preadmission certification, concurrent review, and denial of payment (as a part of the retrospective review program) programs were associated with lower hospital admissions, and fewer inpatient days and payments per 1,000 members. Mandatory second surgical opinion did not have a statistical impact on hospital utilization and payments. The aggregate reduction in hospital payments for all Blue Cross and Blue Shield Plans with both a preadmission certification and concurrent review program was estimated at $2.55 billion in 1988 dollars. For those Plans conducting preadmission certification, concurrent review, denial of payment, and case management programs in 1988, the total per enrollee reduction of inpatient payments was $52.94.

Blue Cross Blue Shield Insurance Plans↗
PubMed1976

PSRO: current status of the professional standards review organization program.

Since Public Law 92-603 was enacted in October 1972 considerable progress has been made in the establishment of Professional Standards Review Organizations (PSROs) for the purpose of determining the necessity, appropriateness, and quality of medical care provided beneficiaries of the major programs authorized in the Social Security Act. Sixty-five conditional PSROs are implementing review in acute care hospitals in their geographic area, and 55 planning groups are developing plans to qualify for conditional PSRO designation. The PSRO hospital review system is based on three interrelated review mechanisms. These are concurrent review, which includes admission certification, and continued stay review through discharge; medical care evaluation studies; and analysis of hospital, practitioner, and patient profiles. This article describes the review system in some detail and the potential opportunities the PSRO program offers to occupational therapists.

Hospitals↗
PubMed1975

The PSRO hospital review system.

The 1972 Social Security amendments contained the landmark Professional Standards Review Organization (PSRO) provisions as well as several sections upgrading existing utilization review (UR) requirements under Medicare and Medicaid. With issuance of the PSRO Program Manual and the recent publication of the new UR regulations, HEW for the first time has brought Medicare and Medicaid hospital review requirements into conformity and made them compatible with and supportive of the PSRO program. This article defines the PSRO hospital review system, describes how the three major components-concurrent review, medical care evaluation studies, and profile analysis-interrelate and provides examples of each of these components. Under utilization review requirements or PSRO, hospitals will be required to implement an integrated system of review designed to assure appropriate utilization practices and improve the quality of care. These aims are to be accomplished through the application of concepts of peer review, the use of norms, criteria, and standards, the identification of deficiencies in the quality, administration, or appropriateness of health care services, and their correction through linkage with programs of continuing medical education. Although PSROs are initially responsible for review in hospitals, they will likely provide the locus for a community-wide system of peer review for all services provided under National Health Insurance.

Evaluation Studies as Topic↗
PubMed1991

Intensive, focused utilization management in a teaching hospital. An exploratory study.

A 3-month study was performed in a teaching hospital to determine the impact of intensive, focused utilization management on the average length of stay and average total charges in a carefully defined group of indigent patients. Prompt admission review was performed, the treatment plan ascertained, and a physician advisor notified. The attending physician was informed by a physician advisor of the patient's financial class, and assistance with expediting patient care and discharge planning was offered. Daily concurrent review monitored the treatment and discharge plans. The study compared 73 patients with a control group of 191 patients of similar financial class and diagnosis related groups (DRGs) for the immediately preceding 3 months. Compared with the control patients, the study patients experienced a 23% decrease in average length of stay and 16% decrease in average total charges. This study indicates that an intensive utilization management effort in a teaching hospital can be effective without compromising the quality of care.

Hospital Bed Capacity, 500 and over↗
PubMed1976

Format review: evaluating implementation of the problem-oriented medical record.

As interest in the problem-oriented medical record (POMR) develops, and more medical settings begin to implement the system, many observers are expressing a desire to know how well the system is being used and accepted. Moreover, settings currently using the POMR system have a need to document the effectiveness of their POMR program as a means of insuring continued progress and for addressing difficulties and obstacles affecting its use. Format review is a technique for reviewing patient records and describing patterns of POMR use. Patient records of an institution are reviewed concurrent to the patient's contact with the institution. Data collected from each record is summarized to provide an overview on patterns of POMR use and to identify areas of difficulty. These findings can serve as the basis for educational and administrative intervention to improve use of POMR. The format review technique is explained and examples of its application are given. The technique has been used at Michael Reese Hospital and Medical Center over the past two years, and has proven to be a useful tool in describing the implementation progress of POMR.

Chicago↗
PubMed1977

The use of computer generated patient profiles to evaluate resident performance in patient care.

This paper describes the way in which data from a computer-based health information system are used to review the service experiences of family practice residents. First, it discusses the development of the patient profiles that provide a chronological account of a patient's visits, their purposes, diagnoses, laboratory procedures, treatments, and outcomes. Then, through four cases, it describes the way in which these computer-generated displays are used by faculty to conduct concurrent reviews of residents' performances, to select medical records for review, and to initiate feedback and instruction to residents as they care for their patients.

Child↗
PubMed1991

Impact of changing attitudes in carotid surgery on community hospital practice.

In 1985, institutional guidelines for the evaluation and performance of carotid surgery were established in our community hospital. During the 5-year period from 1985 through 1989, 159 carotid reconstructions were done. There were four major strokes (3%), one eventually resulting in death, with the second death in this series from a myocardial infarction (mortality 1%). The combined mortality/major stroke morbidity incidence was 3%. Three transient ischemic attacks (2%) postoperatively cleared promptly without residua. During the latter 1980s, an increasing number of vascular surgeons were doing less carotid surgery. Monitoring institutional quality assurance and individual surgeon performance within the community hospital is becoming a reality. Our experience with institutional guidelines for the evaluation and conduct of carotid surgery, together with an assessment of results and ongoing individual surgeon performance, is presented. Maintaining acceptable morbidity and mortality statistics can be enhanced by having a plan for assessment, management, and concurrent review.

Aged↗
PubMed1991

Pulse oximetry monitoring outside the intensive care unit: progress or problem?

OBJECTIVE: To evaluate the use of continuous pulse oximetry monitoring in general care units. DESIGN: Hemoglobin oxygen saturation data collected prospectively by use of pulse oximetry with concurrent review of the medical record. SETTING: General medical-surgical nursing units in a large, tertiary care university hospital. PATIENTS: Forty patients on two nursing units monitored with continuous, bedside pulse oximetry at the request of their primary physicians. MEASUREMENTS: All patients had continuous pulse oximetry monitoring. A research associate visited the bedside two or three times daily and recorded saturation compared with time data from the previous 8.75 hours. Patients were studied for 36 hours or until pulse oximetry monitoring was discontinued. Episodes of desaturation were counted. Patient charts were reviewed for documentation of desaturation in either nursing or physician notes. Orders adjusting oxygen therapy or other respiratory therapy within 12 hours of any desaturation episode were also recorded. MAIN RESULTS: Thirty of the 40 patients (75%) had at least one episode of desaturation to less than 90%; 23 (58%) had at least one episode to less than 85%. Desaturation episodes were documented in nursing notes for only 33% of those patients who desaturated to less than 90% and in physician notes in only 7% of cases. Changes in respiratory therapy were ordered in 20% of patients who desaturated to less than 90% and in only 26% who desaturated to less than 85%. CONCLUSIONS: Despite their repeated occurrence, episodes of hypoxemia were rarely documented in either nursing or physician notes. Further, even in patients who had episodic desaturation, pulse oximetry monitoring had little effect on changes in physician-directed respiratory care.

Adult↗