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At least 19 recordsLinked to original sources
PubMed1975

Emphasizing "level of care" over "length of stay" in hospital utilization review.

Utilization review has heretofore emphasized "length of stay" as the criterion for deciding when the patient is ready to leave the hospital. We suggest that "level of care" (the type, number, and/or intensity of a combination of physician, skilled nursing, and ancillary services) received by the patient should replace length of stay as the major "decision" criterion for deciding on continued hospitalization: "appropriate hospital placement" means the patient is currently receiving a level of care available only in the hospital. Length of stay should be the criterion for signaling intervals when patients are (re) reviewed to determine the currently needed level of care. Explicit criteria for determining when a patient is receiving a hospital level of care should be developed. Explicit criteria will increase objectivity, provide guidance to utilization review coordinators, and assist the hospital in defending its utilization review decisions to an intermediary or Professional Standards Review Organization (PSRO). Level of care will be reflected in a patient's "service profile," a listing of all the services being received by the patient on any given day of hospitalization. The services profile varies throughout hospitalization; hospitalization is appropriate when a patient's current services profile constitutes a level of care available only in the hospital.

Delivery of Health Care↗
PubMed1989

Metoclopramide utilization review.

Utilization review of metoclopramide conducted at the Ambulatory Care Center at the Veterans Administration Medical Clinic in Boise, Idaho, revealed that a substantial proportion of prescriptions were written for indications that were considered inappropriate. After further evaluation, it was found that the medical literature supported metoclopramide use for one of the indications that had been considered inappropriate.

Ambulatory Care↗
PubMed1988

Surgical unit time utilization review: resource utilization and management implications.

As health care providers seek ways to reduce the cost of health care services, hospital operating rooms (ORs) have been identified as potential areas for cost reduction efforts. Cost containment efforts which have shifted significant portions of the inpatient population to ambulatory areas have resulted in an inpatient population which is sicker and more procedure-intensive. Efficient management of operating rooms has assumed even greater importance in this environment. Inefficient or inaccurate scheduling of OR time often results in delays of surgery or cancellations of procedures, which are costly to the patient and the hospital. Approaches to efficient use of ORs include computerized scheduling, utilization monitoring, and refinement of scheduling policies and procedures. In the absence of commercially available software to meet operating room management information needs, Johns Hopkins developed its own system in 1983. This software provides detailed information for daily OR management and long-term planning. The computerized operating room scheduling and monitoring system is described in this article and an operational measure of scheduling accuracy is proposed. Suggestions are made for incorporating this measure into planning and allocation decisions.

Appointments and Schedules↗
PubMed1992

Hospital-reviewer relations and effective utilization review.

A survey of utilization review nurses revealed substantial variation in the relationships between these nurses and the hospitals at which they review cases. Hospitals providing reviewers with complete responses to questions were associated with high levels of utilization review compliance, which was a significant factor in explaining the savings associated with utilization review. Improving relations between hospitals and utilization reviewers may yield higher levels of utilization review compliance and significant cost savings.

Communication Barriers↗
PubMed1988

Potential liability in utilization review.

Increasingly, utilization review activities arising out of the cost containment concerns of third-party payers and the business community are becoming a factor in the health care delivery process. The author focuses on the potential liability of the physician and the utilization review organization when a patient suffers injury following a disagreement about treatment and urges the physician to deliver necessary services according to his or her medical judgments, not the judgement of the utilization review organization.

Cost Control↗
PubMed1999

Drug utilization reviews of oral quinolone, cephalosporin, and macrolide use in nonacute care: a systematic review.

Drug utilization review (DUR) is a tool for monitoring the appropriateness of physicians' prescribing patterns. The present systematic overview was undertaken to determine the extent of appropriate use of oral quinolones, cephalosporins, and macrolides in nonacute-care settings in North America reported in published DUR studies. Potentially relevant DURs conducted since 1987 were retrieved from an electronic search of 6 databases (augmented by manual searches of bibliographies of appropriate articles) and from personal communications with local experts. Independent reviewers applied objective criteria to select the DURs for inclusion. Quality assessments were performed by 4 independent reviewers using the Edmonton Quality Assessment Tool for Drug Utilization Reviews, an instrument developed to assess the potential for systematic bias in a DUR. Data from the studies included were abstracted independently by 2 reviewers using a standard data-collection form. Twelve of 587 (2.0%) articles met the inclusion criteria. Eight studies targeted the appropriateness of prescriptions for ciprofloxacin (appropriateness range, 5% to 95%), 3 included cephalosporins (range, 0% to 100%), and 2 examined erythromycin (40%). There were 2 primary reasons for a rating of inappropriate: (1) the prescription was not first-line therapy, or (2) there was insufficient documentation in the patient record. The designation inappropriate did not mean that the drug did not benefit the patient. Of the 4 intervention-based DURs, 1 study showed a significant improvement in appropriate use. Because of heterogeneity in study design, delivery of interventions, and outcome assessment, a pooled estimate of effect was not derived. Four studies estimated the cost of inappropriate prescribing to the institutional study site, which ranged from $20,500 to $173,359 annually; however, these estimates cannot be generalized because of various limitations. When the 12 studies were assessed for methodologic quality, 1 study was rated as high, 7 as moderate, and 4 as low. Levels of prescribing appropriateness reported in the DUR literature should be interpreted cautiously. The DUR studies included in this review varied greatly in the methodologic rigor applied to sample selection, standardized data collection, application of standardized screening criteria, and validated data analysis.

Bacterial Infections↗
PubMed1992

The impact of utilization review on costs and utilization.

This paper examines the performance of a utilization review program using data from Aetna's utilization review (UR) customers compared to a representative sample of its customers which had no utilization review during the study period. Statistical adjustments were made for the utilization management status, employee demographics, plan benefits, group size, year effects and seasonality. The study period covered from the first quarter of 1987 through the last quarter of 1988. The data suggest that UR reduces overall medical expenses by 4.4 percent, and inpatient expenses by 8.1 percent after a year of experience, largely by reducing length of stay.

Ambulatory Care↗
PubMedDate not supplied

Drug utilization review: mechanisms to improve its effectiveness and broaden its scope. The U.S. Pharmacopeia Drug Utilization Review Advisory Panel.

OBJECTIVE: To address important problems and needed changes in online and retrospective drug utilization review (DUR) programs. Emphasis is placed on reliability of DUR criteria and the shift of traditional retrospective DUR programs toward disease management and health care outcomes. DATA SOURCES: Published literature evaluating the role of online and retrospective DUR programs. STUDY SELECTION: Particular attention was given to studies assessing DUR criteria reliability and new interventions with retrospective DUR programs. DATA SYNTHESIS: A literature review was conducted along with an expert summary from the U.S. Pharmacopeia Drug Utilization Review Advisory Panel. Studies have revealed variations in DUR criteria that could be affecting clinical practice and patient care. Appropriate formal methodologies and use of consistent procedures in developing online prospective DUR programs and systems could help resolve these problems. Traditional retrospective DUR is also shifting to incorporate disease management and methodologies from health outcomes and pharmacoeconomics studies. CONCLUSIONS: Refinements are needed to improve the reliability and validity of online DUR criteria and to minimize false positive messages. Databases created as a result of DUR efforts have been used in new and innovative ways to incorporate health outcomes data and disease management interventions. Additional outcomes data, combined with quality assurance efforts, should increase the utility of DUR/disease management efforts in evaluating health systems while improving the effectiveness and efficiency of pharmacists' health care interventions.

Computer Systems↗
PubMed1997

Comparing results of concurrent and retrospective designs in a hospital utilization review.

Hospital utilization reviews are performed on the basis of lists of explicit criteria, such as the Appropriateness Evaluation Protocol, both concurrently and retrospectively, in an increasing number of settings as part of efforts to improve the performance of hospitals and to reduce health care costs. Retrospective data collection has advantages in terms of expenses and ease of sampling, but relies on the quality of medical records. We report on a comparison between concurrent and retrospective data collection performed simultaneously and independently by two reviewers on the same hospital stays in the regional St-Loup Hospital. Results suggest that retrospective data collection produces higher rates of inappropriate hospital utilization, due to a limited number of criteria that are recorded concurrently, but are not found in the retrospective reading of medical records. These results should encourage a further investigation of the comparability between concurrent and retrospective designs in other settings.

Concurrent Review↗
PubMed2000

Edmonton Quality Assessment Tool for Drug Utilization Reviews: EQUATDUR-2: the development of a scale to assess the methodological quality of a drug utilization review.

OBJECTIVE: The objective of this study was to develop an instrument that will assist in evaluating the methodological quality of drug utilization reviews (DURs) and studies of prescribing appropriateness. DESIGN: An expert committee followed accepted steps for developing and testing new instruments. Consultations on content, face validity, and scoring of items were solicited from external experts. Seven raters tested an initial version; subsequently, a refined instrument was designed. The Edmonton Quality Assessment Tool for Drug Utilization Reviews (EQUATDUR-2) evaluates 3 domains: sample selection (1 item), data collection (1 item), and data analysis (3 items). Sixteen raters tested EQUATDUR-2 on a random sample of DURs. MEASURES: The study measures were reliability-using random effects interclass correlation coefficients for ratings by individual raters (ICC2,1) and the mean of ratings (ICC2,k)-and variability between DUR quality levels and rater groups. RESULTS: There were significant differences in methodological quality (P <0.001) and in mean scores comparing low-, moderate-, and high-quality DURs. Nonmethodologists' ratings exhibited significant variability (P = 0.03) and tended to be higher. Agreement varied for individual items (ICC2,1, 0.22 to 0.44; ICC2,k, 0.81 to 0.91) and for mean summary ratings (ICC2,1, 0.42 [95% CI, 0.28 to 0.61]; ICC2,k, 0.92 [95% CI, 0.86 to 0.96]). The average time to rate each DUR was 10.0 minutes (95% CI, 9.2 to 10.9). CONCLUSIONS: EQUATDUR-2 is a succinct, self-administered instrument with evidence of validity and reliability. We recommend that > or =2 raters independently assess each DUR and resolve disagreements by consensus. EQUATDUR-2 will help clinicians and decision makers to evaluate the quality of DUR studies and provide a framework for enhancing rigor in the design, conduct, and reporting of DURs.

Alberta↗
PubMedDate not supplied

Clinical and fiscal outcomes of utilization review.

Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.

Case Management↗
PubMedDate not supplied

Drug utilization review of sedative/hypnotic agents in Texas Medicaid patients. Texas Medicaid Vendor Drug Program Drug Utilization Review Board.

OBJECTIVE: To assess use of sedative/hypnotic agents in Texas Medicaid patients and evaluate practitioner receptiveness to intervention letters concerning sedative/hypnotic prescribing generated by the Texas Medicaid Drug Utilization Review (DUR) Board. DESIGN: Retrospective DUR. SETTING: Texas Medicaid retrospective DUR program. PATIENTS OR OTHER PARTICIPANTS: 244 Texas Medicaid patients and 291 Texas physicians. INTERVENTION: Patient profiles for Texas Medicaid patients were reviewed retrospectively to quantify sedative/hypnotic prescribing practices. Intervention letters were prepared and sent to physicians directly involved in the care of patients receiving excessive sedative/hypnotic therapy. Physician responses were categorized based on information presented in the intervention letter and circumstances surrounding the identified patient. Prescribing practices were assessed approximately 1 year after the intervention to determine the impact of intervention letters on prescribing. MAIN OUTCOME MEASURE: Physician response to intervention letter. RESULTS: Responses were received from 208 of 291 physicians (71.5%). Approximately 40% of physicians agreed in principle with the suggestions offered by the Texas Medicaid DUR Board to minimize chronic sedative/hypnotic use. Almost one-half of these physicians had discontinued sedative/hypnotic therapy for the identified patients 1 year after the intervention. Approximately 9% justified continued sedative/hypnotic use based on patient diagnosis or refractory response to treatment, and 55 physicians (26.4%) were unwilling to alter therapy because of patient-specific factors. CONCLUSION: Through the use of retrospective DUR, Texas Medicaid patients receiving excessive amounts of sedative/hypnotic agents were identified and improvements in sedative/hypnotic therapy were initiated. DUR can be useful not only in identifying problem areas, but also in encouraging physicians to modify prescribing practices through educational means.

Adolescent↗
PubMed1979

Utilization review and containment for hospital utilization: some implications of providing care in the "most appropriate setting".

The study examines the potential for savings in the use of hospital resources if utilization review policies succeed in curtailing excessive use of hospital facilities. Excessive use is defined as the utilization of hospital care when ambulatory care is medically feasible and acceptable. A utilization review policy would be expected to counteract the tendency to substitute inpatient for outpatient treatment by assuring that all patients with identical medical problems and demographic traits would be treated in an identical least cost setting regardless of their social and economic circumstances. It might, thus, ascertain that the use of hospital facilities would not be systematically affected by patients' non-medical or socioeconomic characteristics. Specifically, the study distinguishes between two types of utilization control policies, pre-admission certification and concurrent or continuing-stay review of hospital episodes, and asks how each can contain excessive utilization. It concludes that continuing-stay review is not likely to have any appreciable effect on shortening hospital episodes because the effects of nonmedical factors on extended stay are small and concentrated among patients whose diagnoses might not qualify them for hospitalization under a pre-admission screen. However, pre-admission certification has a considerable potential for containment of hospital utilization through the reduction in the number of admissions. Also, as a corollary, the study shows that utilization review policies should not be evaluated, as they often are, in terms of their effect on length-of-stay, but rather in terms of their effects on hospital admissions and case mix.

Analysis of Variance↗