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PubMed1991

[A utilization review program of cefoxitin].

A drug utilization review program of cefoxitin was conducted in a 714-bed teaching hospital. Health records of all 43 in-patients who received cefoxitin during the month of November 1987 were reviewed retrospectively. The use of cefoxitin (47 courses) was evaluated on the basis of "appropriate use" criteria developed from the literature and the physician's clinical experience. Of the 47 courses evaluated, cefoxitin was prescribed for prophylaxis in 47%, and its use was considered inappropriate in 86% of these. Overall, 66% of total cefoxitin usage was deemed inappropriate in this hospital. The cost associated with inappropriate use was estimated at $2672 for the period of the study. Corrective measures were then implemented to rectify the identified problems. A second study was conducted 2 years later to assess the impact of the corrective measures. This utilization review program of cefoxitin showed that optimal use of a drug requires not only close collaboration between pharmacists and physicians but a continuous and not a sporadic process of surveillance of the prescription for the drug being studied.

Bacterial Infections↗
PubMedDate not supplied

Utilization review and the family physician.

Family physicians are often in close contact with utilization review programs. Traditional hospital based review programs have included prehospital certification, outpatient and same-day surgery, second opinions, concurrent hospital review, and early discharge planning. The role of utilization review in ambulatory care is expected to increase in the future and will focus on the cost-effective allocation of resources. Family physicians need to be aware of several issues as they interact with utilization review programs, including the preservation of confidentiality, financial obligation in the face of negative review decisions, and the effect of utilization review on liability for adverse outcomes. Family medicine education should encourage familiarity with the structure and function of review programs and should enable practitioners to participate intelligently in such programs.

Adult↗
PubMed1994

Utilization review for Medicaid diagnosis-related group systems: practice, innovation, and lessons of experience.

Utilization review practices, innovations and trends for the 21 states using diagnosis-related groups for Medicaid during 1992 are described. According to this descriptive survey, Medicaid inpatient utilization review programs vary widely in authority, approach and focus, reflecting state payment system incentives, health and hospital system characteristics, and provider practice norms. More than half of the states with Medicaid diagnosis-related group systems contract with a Medicare Peer Review Organization. State programs are developing complementary clinical and data analytic approaches, advised by multidisciplinary utilization review committees, and are moving from random review to strategies that focus on specific types of admissions/procedures, and shift as provider practices and utilization patterns change. Utilization review strategies also support payment incentives and system features, e.g., by targeting outliers, readmissions and transfers, and short stays. Overall, programs are becoming more flexible, targeted, and interactive. Trends and suggestions for refining utilization review programs for diagnosis-related group systems are presented.

Data Collection↗
PubMed1987

Utilization review of psychiatric day hospitals in a Canadian urban region. I. The service profile.

This article reports on a study which reviewed the utilization of six adult psychiatric day hospitals in a Canadian urban region. The study looks at the utilization of services through the examination of clinical service staffing patterns, accessibility, and gaps in service. It is hoped that this comprehensive overview will promote the establishment of standards and guidelines for psychiatric day-hospital services and further enhance the overall planning for psychiatric services in the region.

Adult↗
PubMed1986

[A study of utilization review in hospitals--focusing on medical statistics].

It is a matter of course that health care is an important issue closely related to the daily life of residents. In this situation, university hospitals, although their main aim is research and education, also play a significant role as core hospitals in various regions of the community. By reviewing hospital utilization, extended to facilities in a given area, we first analyzed the medical service area and the length of stay in the hospital affiliated to the University of Occupational and Environmental Health, on the basis of discharge various directions of facility planning based on future bed using control, including addition of beds, and also attempted to evaluate the actual state of annual facility management with the aid of computer.

Catchment Area, Health↗
PubMed1995

Recent state legislative approaches to regulating utilization review reflect URAC national standards.

As state legislatures begin to regulate utilization review activities, some appear to be utilizing the URAC standards for guidance. Still others (e.g., Iowa, Nebraska, and New Hampshire) require URAC accreditation as a prerequisite for utilization review organizations to operate in their states, while others (e.g., Alabama, Arizona, Connecticut, Indiana, North Dakota, Tennessee, and Rhode Island) accept URAC accreditation in lieu of state certification. "States Look to Accreditation for Managed Care Seal of Approval," Medical Utilization Review, Vol. 22, No. 20, Oct. 27, 1994, at 7-8. The remarkable consistency between the 1994 URAC standards and the new California law are a hopeful sign that managed care decision-making will in the future be undertaken on a more uniform and objective basis. Only through this type of consensus building will the historical chasm between providers and payors be made smaller.

California↗
PubMed1977

Cost, utilization, and utilization review of mental health services in a prepaid group practice plan.

The author describes the utilization review process, utilization patterns, and service cost of the Mental Health Service of the Health Insurance Plan of Greater New York (HIP). He finds that a mental health care delivery system within a health maintenance organization offers the advantages of sophisticated utilization review procedures, reduced cost per mental health incident, and a low utilization rate and low cost for psychiatric hospitalization. However, the HMO's return-to-function treatment goals may be too limited for the minority of patients who would benefit only from long-term intensive treatment. He recommends that cost accounting be based on cost per illness rather than cost per service.

Accounting↗
PubMed1988

Hospital utilization review: past experience, future directions.

Utilization review (UR) programs seek to determine whether specific services are medically necessary and whether they are delivered at an appropriate level of intensity and cost. Although UR programs have been operating for more than 40 years, they have changed dramatically during the past two decades. Today, many health care providers, analysts, and policymakers view UR as a possible solution to hospital inpatient cost and quality problems. This paper addresses how UR has evolved, how UR is used today by different delivery mechanisms (i.e., Medicare, health maintenance organizations, preferred provider organizations, Blue Cross, and commercial insurers), the cost effects of various UR approaches, and how UR will be used in the future.

Blue Cross Blue Shield Insurance Plans↗
PubMed1990

Statewide helicopter utilization review: the Massachusetts experience.

Air medical services began in Massachusetts in 1982, and Utilization Review (UR) of both programs in the state began in 1985. The UR program consists of external review of all flights according to screening criteria established by an independent Helicopter Utilization Review Committee (HURC). Between 1982 and 1989, over 2,500 flights were reviewed, with under 2% deemed inappropriate by the committee. Results of this process have helped to improve referrals from specific prehospital and hospital care providers, identified specific patient groups of interest, such as those transported for transplants or because of hospital bed shortages in specific regions, and assisted with improved third party reimbursement. Utilization review has not yet assisted with identification of unmet need or inappropriate resource utilization by ground ambulances, and has not compared the outcome of equal levels of care provided by different transport modes. We conclude that a coordinated utilization review process can be of benefit to both patients and air medical services.

Aircraft↗
PubMed1995

Effect of utilization review in a fee-for-service health insurance plan.

BACKGROUND: Although utilization review is widely used to control health care costs, its effect on patterns of health care is uncertain. METHODS: In 1989, New York City and its unions temporarily replaced actual utilization review with sham review for half the participants in the city's fee-for-service health insurance plan. We compared the health services provided to 3702 enrollees whose requests were subjected to utilization review (the review group) with the services provided to 3743 enrollees whose requests received sham review and were automatically approved for insurance coverage (the nonreview group). The enrollees, physicians, and hospitals were all unaware of the group assignments. RESULTS: During the study period (mean duration, eight months), the members of the review group underwent 1255 procedures in 20 categories of procedures for which second opinions were required (such as breast, cataract, foot, hernia, and hip-replacement surgery, as well as hysterectomy and coronary bypass surgery), and the members of the nonreview group underwent 1365 procedures (P = 0.02). The members of the review group had 124 fewer procedures in doctors' offices and hospital outpatient departments (P = 0.002). In the following year, the members of the review group underwent 248 procedures from the 20 categories, and the members of the nonreview group underwent 234 (P = 0.46). No other differences in patterns of care were found between the groups, including rates of hospital admission to medical-surgical, substances-abuse, or psychiatric units; average lengths of hospital stay; the percentage of enrollees who received preadmission testing; or rates of use of home care. During the study period, the mean age-adjusted insurance payments per person were $7,355 in the review group and $6,858 in the nonreview group (P = 0.06). CONCLUSIONS: The utilization-review program reduced the performance of diagnostic and surgical procedures for which second opinions were required and did not merely delay them until the following year. Otherwise, the program had little effect. Alternatively, actual review and sham review may both have decreased the use of hospital services, with patients or their physicians choosing more efficient treatment when they believed that care would be reviewed.

Case Management↗
PubMed1989

The utilization review program. Essential for hospital survival.

The survival of a health care institution in today's economic climate is dependent on, among other things, the efficiency of its utilization review program. The purpose of this article is to serve as a basic guideline for an institution to develop an adequate utilization review program. It emphasizes that a utilization review program is essential for the economic survival of any health care industry. The utilization review program should be an integrated organization with the support of administration, and the participation of staff physicians, physician advisors, review nurses, and important hospital departments, such as social service, laboratory, medical records, preplanning, and so forth. Following the format presented in this paper, an institution may easily develop a utilization review program. The ideas presented in this paper have been time-proven at our institution. There must be educational programs for physicians on the basics of managing patients according to the prospective payment system and the economic impact physicians can make on the hospital's economic status. These educational presentations must take place as often as necessary to reinforce policy and procedure, and to carry out effective patient management. The utilization review department, as well as the medical staff, must work in close harmony with administration to assist the facility in surviving trying economical times.

Hospital Administration↗
PubMed2003

Nurses' ethical conflicts in performance of utilization reviews.

This article describes the ethical conflicts that a sample of US nurse utilization reviewers faced in their work, and also each nurse's self-reported ethical orientation that was used to resolve the dilemmas. Data were collected from a sample of 97 registered nurses who were working at least 20 hours per week as utilization reviewers. Respondents were recruited from three managed care organizations that conduct utilization reviews in a large midwestern city. A cross-sectional survey design was used to collect demographic data and to ask closed-response, short-answer and open-ended questions. Ethical conflicts reported by nurses were similar across utilization review settings and many were justice orientated. Self-reported ethical orientations were similar across organizations, with beneficence dominating. Implications of these findings are discussed.

Adaptation, Psychological↗
PubMed2005

Responses of hospital utilization review staff to reimbursement denials.

Utilization review (UR) is a strategy used by the managed care industry to monitor and control utilization of health care resources. The concurrent UR process requires that hospital staff report clinical information to payers, who either certify or deny reimbursement. Conflicts may arise when hospital staff disagree with denial decisions. The authors analyzed the various responses of a medical center UR staff to payer denials and found that although denials were not frequent, they were perceived negatively by hospital staff. Improving and standardizing communication among providers, payers, and patients is one means of reducing conflict and frustration in the event of reimbursement denial.

Academic Medical Centers↗