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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↗
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↗
PubMed1979

Jefferson Medical College Student Model Utilization Review Committee.

A Student Model Utilization Review Committee Project is in progress at Jefferson Medical College. Students participate in the program for 90 minutes during the six weeks of their clerkship in family medicine at the university hospital. Information collected from participants and controls before and after the program indicates that the experimental group has greater knowledge and more positive attitudes about utilization review and cost control in the health care field than do the controls. Students express positive feelings about the program. More importantly, one year later, as seniors, those in the experimental group demonstrated clinical behavior which was more consistent with the objectives of the program than other students. These results have led the Department of Family Medicine to incorporate the utilization review program into its formal curriculum beginning in the 1979-1980 academic year.

Cost Control↗
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↗
PubMed1976

Automated utilization review is timely, accurate, efficient.

Federal utilization review regulations require that hospitals establish admission and extended stay certification processes and conduct medical care evaluation studies. The computerized review system in use at Deaconess Hospital, St. Louis, has satisfied these regulations with minimum expenditure of time, effort, and money while insuring maximum accuracy and timeliness and consistency of reporting.

Computers↗
PubMed1978

The dynamics of utilization review: a case study of 44 Massachusetts hospitals.

Utilization review programs have existed on a national basis for over a decade, but relatively little is known about the patients who are scrutinized and what actions are taken to correct unnecessary use. In the fall of 1976, 44 of the 122 Massachusetts hospitals participated in a two-week in depth study of their utilization review activities. Over 22,000 admission and extended stay reviews were performed during this time period, and of these, 2,120 patients' continued stays in the hospital were questioned. In five admission review cases and 79 extended stay review cases, the UR committee formally terminated continued health insurance benefits, and in 12 admission reviews and 74 extended stay reviews, questioning by the UR committee led the attending physician to discharge the patient earlier than would have otherwise occurred. Ninety-four percent of the terminations occurred in Medicare patients and the median age of these patients exceeded 80 years. For medical patients, a disproportionate share of all those cases questioned and of those terminated occurred in chronic illness categories, such as cancer, heart failure, and organic brain syndromes. A higher than expected percentage of surgical cases questioned by the UR committee were in neurosurgical, cardiovascular and orthopedic procedure groups. The frequency with which UR committees identified and acted upon cases suggests that effective self-policing is occurring. A large portion of the utilization problem, however, may be related to the unavailability of appropriate sub-acute care for patients with chronic medical illness or surgical procedures which require long postoperative rehabilitation and recuperation.

Concurrent Review↗
PubMed1976

The effect of a target date based utilization review program on length of stay.

This study was conducted to determine whether implementation of a specific formalized concurrent utilization review system which involved making a prior determination of length of stay had any more effect on average length of stay than continuance of a utilization review method not involving assignment of such a target date. The system studied was the Pre-Discharge Utilization Review (PDUR) program used for Medicaid patients in Pennsylvania. Analysis was conducted using discharge abstracts for Medicaid patients under age 65 who were discharged with one of 14 common diagnoses for certain Allegheny County hospitals in 1972 and 1973. Comparisons were made for each individual diagnosis to control for possible differences in case mix. Results indicate that there was no general reduction in length of stay which could be attributed to the PDUR program.

Female↗
PubMed1975

Applying utilization review procedures in a community mental health center.

A large, multiservice community mental health center operates a utilization review program based on a three-level system of chart review by medical records personnel, a utilization review technician, and a committee of clinicians. Review is facilitated by a checklist for use in rating such issues as comprehensiveness, coordination, and quality of care aginst standards of care developed by the director of each service. The incompleteness of charts pulled for review is a continuing problem. But the system makes for efficient review and has various secondary benefits, such as the improvement of medical records. A survey made in the first year showed that staff had mixed feelings about the need for review, but that 60 per cent thought it was helpful all or most of the time.

Attitude of Health Personnel↗
PubMed1975

Utilization review of treatment for suicide attempters.

The authors describe an effort to develop criteria for utilization review of treatment for suicide attempters. Explicit criteria proposed by a panel of experts as essential determinants for hospitalization of these patients were compared with actual clinical practice. It was found that according to the experts' criteria (which were operationalized into rating assessments), over half of the outpatient sample should have been hospitalized. After multiple regression analysis was carried out on the criteria, however, four predictors showed that only 20 percent of the outpatients should have been hospitalized. The authors discuss the issues these findings raise about the criteria of the experts, their utility for research, their validity, and their implications for utilization review.

Decision Making↗
PubMed1976

The use of utilization review records as a source of data on nursing home care.

Data form the Utah nursing home Utilization Review Program, 1970-73, provide a description of the population of nursing home patients in Utah and changes over time in patient medication and measures of activity. These data are analyzed according to type of care in home: personal, intermediate, or comprehensive. The collection of data in utilization review programs can help to evaluate the quality of care as well as appropriateness of placement, provided the information collected is designed with these ends in mind.

Adult↗
PubMed1979

Utilization review and resident education.

The reasons for psychiatric hospitalization are not always taught clearly and formally to psychiatric residents; screening criteria employed in utilization review can be a tool for helping residents gather data and make decisions about the admission or continued stay of patients. On the admitting and inpatient units of the Payne Whitney Psychiatric Clinic, residents use sets of criteria for admission and for continued stay, with accompanying guidelines and clinical examples, as part of their training. The authros outline principles used in developing the criteria, including the belief that they should be applicable independent of diagnosis. They suggest that in a teaching hospital screening criteria should be taken as standards, and that they should be developed as part of the educational program and only then introduced into utilization review.

Decision Making↗
PubMed1975

Utilization review and suicide attempts. Exploring discrepancies between experts' criteria and clinical practice.

The discrepancies between experts' criteria for hospitalization of suicide attempters with actual clinical practice were explored to develop utilization review criteria which reflect current clinical thinking and which could form guidelines for the assessment of clinical care. Experts' criteria predicted that a hospitalized group of suicide attempters did not require hospitalization and that a nonhospitalized group of suicide attempters required hospitalization. Examination of the discrepancies between clinical practice and experts' criteria not only revealed that incorporation of clinical measures of depressive symptomatology could improve the experts' criteria for hospitalization but also showed that clinicians did not hospitalize a group of markedly symptomatic and socially impaired white suicide attempters. Clinician and patient factors that may have contributed to this decision making and the application of these findings for utilization review are discussed.

Adolescent↗
PubMed1977

Utilization review of the late adolescent patient in a mental health center: steps toward the development of criteria for the adequacy of assessment and treatment.

This study is concerned with an attempt to determine whether meaningful utilization review criteria could be productively generated by viewing a patient population from a developmental perspecitve. During a 2-year period, a multidisciplinary panel at Yale University sought to identify the sociodemographic, clinical, and administrative issues posed by late adolescents seeking treatment at the Connecticut Mental Health Center, New Haven. We sought to address the following questions: a) From what segment of the population were we drawing our adolescent patients? b) Who referred them for help? c) What kinds of problems led to referral? d) What were the diagnostic characteristics of the adolescent's evaluation? e) Under what conditions do adolescents terminate treatment? The charts of over 1222 adolescent patients were studied to help us answer these questions. Our investigation revealed that the adolescent patients seen at the Mental Health Center were sociodemographically and diagnostically heterogeneous. An increasingly large number of adolescents are referring themselves for evaluation and treatment, rather than being sent by schools, physicians, or social welfare agencies. The majority of patients seeking help come from blue collar or working class backgrounds mainly because of intrapsychic complaints of anxiety and depression. Upwardly mobile, they constitute a group who have completed their high school education, often live away from home, and are struggling with problems of defining an identity different from that of their family. Review of their charts indicated that significant sholastic, medical, and developmental information was frequently lacking or vaguely recorded. Our chart review also indicated that many clinicians did not ask their patients about symptoms relating to body functioning such as difficulties with sleeping, eating, or psychosomatic complaints. The study also discovered that it was difficult in the great majority of the charts reviewed to specify the adolescent's own perception of the difficulties which led them to seek help. Suggestions are then outlined for developing review criteria dealing with the emancipated adolescent, parental involvement in the treatment of the adolescent, treatment plans, and the termination of treatment. The comparative advantages of combining utilization review criteria from both a traditional "disease model" and a "developmental model" are discussed. The panel concluded that input from both perspectives is necessary in understanding the impact of a mental health delivery system upon adolescent patients, their family, and the community.

Adolescent↗
PubMed1977

A suggested schema for utilization review for a Community Mental Health Center.

Three record-keeping models were examined by an interdisciplinary committee at the Rochester Mental Health Center to see which would best meet the needs for a standardized record format that could be used by an outpatient comprehensive community mental health center. The systems examined were: (1) Model Criteria Set, (2) Problem Oriented Record, and (3) a Combination Diagnosis and Standardized Problem List. A modification of the Combination System used at the Cleveland Metropolitan General Hospital was developed. Using this tool, an audit committee began the process of Utilization Review. It is a suggested schema to other outpatient mental health centers who are in the process of developing a utilization review process.

Community Mental Health Services↗
PubMed1975

Developing a utilization review model for community mental health centers.

During their struggles to develop a utilization review model for a community mental health center, members of an interdisciplinary committee identified several issues they believe are important in establishing such a model. They include comprehensiveness of participation and of areas for review (the review committee should represent all disciplines and programs, and should be concerned with any aspect of center functioning), a problem-review approach in which subcommittees carry out documented studies of issues or problems, and specific provision for feedback and implementation of the results.

Community Mental Health Services↗
PubMed1975

Utilization review of treatment of suicide attempters: chart review as patient care evaluation.

The authors reviewed the charts of 36 nonhospitalized suicide attempters who were identified by utilization review as requiring hospitalization. In 16 of the cases, the authors judged the treatment given to have been adequate because of an absence of a history of psychiatric treatment and/or the rapidity with which outpatient treatment was instiituted. Ten of the cases were judged to have been inadequately treated. This finding pointed to have been inadequately treated. This finding pointed to specific deficiencies in the training of residents and the delivery of psychiatric services and illustrates how chart review can be used to upgrade psychiatric care.

Adolescent↗
PubMed1976

Quality assurance: the cost of utilization review and the educational value of medical audit in a university hospital.

The components of mandated quality assurance, that is, utilization review (UR) and medical audit, have been analyzed to determine their cost-effectiveness and educational value in a university hospital. At Ths in 1975 were $205,272--$6.71 per admission or $0.69 per patient day. The average costs per admission and per patient day in teaching hospitals in the New York area in 1975 were $10.42 and $0.93, respectively. It is anticipated that these costs will increase markedly in 1976 because of admission review. Since 1972 approximately 9,500 hospital charts have been reviewed annually to identify an average of six patients per year who required the intervention of the UR committee because of unnecessarily prolonged length of stay. The cost of identifying each patient was $33, 212. In the university hospital, the active participation of the graduate (house) staff in patient care renders the requirements for certification/recertification of the need for hospital services or admission review superfluous. From September, 1973, through December, 1975, 15 studies of evaluation of medical care (medical audit) have been completed at an average cost of $4,788 per audit. In ten audits the principal criticism was inadequate documentation of data in the hospital record. Nine audits were critical of excessive use of laboratory services and deviations of practice were identified in seven audits. Medical audit has failed to achieve its objective to identify the educational needs of the hospital staff. It is suggested that a more satisfactory and less costly form of medical audit should be devised. Clinical studies, published in scientific journals, should be considered in the context of medical audit.

Adolescent↗