A methodology for timing reviews of inpatient hospital stay.

OBJECTIVE: This paper aims to describe a methodology to inform decisions about the optimal time to schedule reviews of a patient's hospital stay and to provide an example of its implementation. METHOD: Length of hospital stay was assessed in 1227 consecutive inpatient admissions. Data were transformed to reflect the probability of discharge from hospital in the following 7 days. RESULTS: The resulting data reflected the points at which the conditional probability of being discharged were declining, revealing the potentially efficient times to conduct reviews of inpatient admissions. CONCLUSIONS: The methodology outlined appears useful in assisting psychiatrists responsible for inpatient care to decide upon optimal times to review a patient's stay in hospital.

An exploratory cost analysis of performing hospital-based concurrent utilization review.

OBJECTIVE: To determine the costs associated with conducting concurrent utilization review, a utilization management strategy widely used by the managed care industry. STUDY DESIGN: A production process model focusing on resource utilization. SUBJECTS: The 29 clinical services of a 500-bed academic health center were aggregated into 9 clinical groups. A random sample of at least 15 reviews per group was studied. METHODS: Time sampling and cost analysis methods were used to determine the cost to the hospital of conducting utilization review. Component activities of the process were identified and analyzed to determine differences among clinical services and among the component tasks of the utilization review process. RESULTS: In 12 months, 13 126 reviews were completed in an average of 15 minutes 41 seconds. Across clinical groups, the average total time of each review ranged from 11 minutes 18 seconds (medical group) to 19 minutes 4 seconds (pediatrics group). Significant differences existed among clinical service groups for the activity of preparing for conducting the review, with the pediatrics group spending more time than the cardiology and oncology groups. The total cost of the process was nearly dollar 166 000 annually. The average cost per review was dollar 11, the average cost per patient-day denied was dollar 478, and the average cost per patient denial was dollar 1592. CONCLUSIONS: These figures are conservative in that they do not include the payer component of the costs, which could be as high as the hospital provider cost. Given a denial rate of < 2% and the high cost of the process, it may be beneficial to investigate alternative processes for conducting utilization review.

To stay or not to stay. The assessment of appropriate hospital stay: a Dutch report.

OBJECTIVE: To adjust the adult-medical Appropriateness Evaluation Protocol (AEP) into a valid and reliable instrument for use in the Dutch health care system, to assess the appropriateness of hospital stay and to identify the causes of inappropriateness. DESIGN: The appropriateness of hospital stay was assessed in a cross-sectional survey on a sample of over 4500 days of stay using a modified, Dutch version of the Appropriateness Evaluation Protocol (D-AEP). SETTING: The appropriateness of stay was assessed in five internal and surgical departments for adult acute care in the University Hospital of Maastricht, a 700-bed hospital with a teaching and regional function, located in the southern part of the Netherlands. RESULTS: The results showed that over 20% of the hospital stay was inappropriate. Half of the inappropriate hospital stay (45.1%) was due to (internal) hospital procedures. The D-AEP proved to be valid (kappa = 0.76; 95% confidence interval (95% CI) 0.68-0.84), reliable (kappa = 0.84; 95% CI 0.75-0.93) and easy to use. CONCLUSION: A substantial proportion of hospital stay was found to be inappropriate, due to hospital procedures and the inability to refer patients to other care facilities or care providers. The D-AEP can be used for monitoring the appropriate hospital stay and in detecting possible causes of inappropriate stay. Analysis of the causes of inappropriate hospital stay provided useful data for improvement actions.

[Corroboration of concurrent assessment of inappropriate hospitalization with retrospective evaluation based on patient records]. / Ubereinstimmung einer zeitgleichen Bewertung von Fehlbelegung mit deren retrospektiver Beurteilung anhand von Patientenakten.

BACKGROUND AND PURPOSE: Since the availability of a German adaptation of the "appropriateness Evaluation Protocol" (AEP) for hospital utilization review, physicians and health care managers were concerned about a potential overestimation of the extent of inappropriate hospital use in a retrospective assessment. The objective was to assess the agreement of concurrent and retrospective assessment of inappropriate hospital use. METHODS: The appropriateness of 42 admissions to surgical wards in a teaching hospital was tested concurrent to the admission. In 25 hospitalized patients the appropriateness of hospital days was assessed. Results were compared with the retrospective testing of the same patients after three months. RESULTS: Agreement between concurrent and retrospective assessment within the same reviewer was 86% of admissions (95% CI = 75%-96%) and 96% of hospital days (88%-100%). Kappa showed values of 0.85 and 0.78, which can be described as excellent. A comparison of two different reviewers, one testing concurrently, the other retrospectively showed agreements of 86% and 90%. The proportion of inappropriate days was the same in both designs. CONCLUSIONS: The results refute prior concerns that a retrospective assessment of the appropriateness of hospital use is impossible because in a retrospective design important clinical information would remain unconsidered or clinical information not yet available at that time would be used for the evaluation. The possibility of an incorrect assessment due to a retrospective design is within the variability inherent to the instrument. Despite the strong agreement, the small sample of surgical patient limits the generalizability of results.

Utilization care plans and effective patient data management.

This article introduces the concept of a utilization care plan (UCP) for supporting the communication of data required for effective utilization review and utilization management. Utilization review is a process of measurement that compares the performance of a ward, department, or entire facility against accepted criteria to identify resource use shortfalls. Utilization management is the deliberate action by third party payers to ensure that shortfalls in resource utilization are minimized. Critical to the success of utilization management is effective data communication; utilization review data must be accurate, complete, accessible, timely, and coordinated. Computer-based UCP systems can remind caregivers when and what services should be provided to patients and also monitor the portion of those services that should be administered during each phase of a patient's therapy. Deviations from the UCP system template constitute variances that can be documented and highlighted in a friendly automated system that ensures highly accurate and extremely timely concurrent utilization information. Some implications of using UCP systems for future research and practice are also discussed.

Relationship of physician ratings of severity of illness and difficulty of clinical management to length of stay.

In a concurrent prospective study, medical and surgical residents rated the severity of illness and difficulty of clinical management of each of their patients within 24 hours of admission, and on a daily basis throughout the patient's stay. Data were collected on consecutive admissions resulting in 661 admissions with complete data for analysis. Results indicate that difficulty and severity are correlated, each explaining variations in length of stay (LOS), and together explaining up to 44 percent. Four alternative measures are tested, first-day values, average values over the stay, peak or highest values, and a zero-one measure indicating whether or not the severity or difficulty fluctuated over the stay. First-day and average measures of severity and difficulty explain little variation in LOS; peak and fluctuating measures are highly explanatory. After adjusting for diagnosis-related groups (DRGs), fluctuating severity adds 34 percent, and adjusting for both DRGs and severity, fluctuating difficulty adds 10 percent for a total of 53 percent variance explained. In comparable results, peak severity adds 21 percent, and peak difficulty 4 percent, for a total of 34 percent variance explained. Findings indicate that difficulty had independent value as a predictor, and the high explanatory power of the fluctuating measures suggests that a third dimension, instability, may be as important as severity and difficulty in explaining LOS.

An examination of adverse drug event monitoring practices in U.S. hospitals.

Unfortunately, the reasons for respondents' negative attitudes and perceptions toward ADE monitoring are not entirely clear because they generally are not related to time or staff constraints. There was some indication that poor medical record documentation was a contributing factor; however, this problem can be addressed through education of physicians and nurses as to the importance of capturing and reporting ADE data. Other research has demonstrated that substantial effort and diligence are required on the part of all members of the health care team to capture ADEs consistently. Fortunately or unfortunately--depending on the perspective--the motivation and at least the initial energy to establish and maintain an effective ADE monitoring program have to come from the pharmacy department. The greatest fear is that many pharmacists simply will be apathetic to the issue and not devote the time and energy necessary to capture and process ADE information effectively.

Impact of pharmaceutical sales representatives on physician antibiotic prescribing.

This study revealed a significant impact on physician prescribing practices by PSRs, based on the results of evaluations of each agent's average number of new prescriptions per month, number of grams dispensed per month, and dollar values of those prescriptions. Comparisons of these data to regional, national, and world trends revealed no correlation.

Onsite concurrent review: impacts on utilization, medical complications and expense.

An evaluation of onsite concurrent review over and above the effects of Aetna's precertification program demonstrated reduced utilization and expenses, especially for ancillary services, and no adverse effects on rates of medical complications.

Hospital-based utilization management: a cross-Canada survey.

Utilization management attempts to measure, understand and, when appropriate, reduce hospital use. We conducted a telephone survey to determine the status of utilization management in Canadian hospitals. The sample comprised a random selection of 30% of acute-care hospitals with over 100 beds for adults in Ontario and Quebec and all such hospitals in the other provinces. Of the 123 chief executive officers contacted 99 (80%) claimed to have a utilization management program. Of those, 90 (91%) agreed to participate in an in-depth survey or to designate a senior administrator to be interviewed who was most knowledgeable about the program. High occupancy rates and funding issues were the most common environmental triggers for the development of utilization management programs; funding issues were listed more frequently by respondents in Ontario than by those elsewhere (p = 0.0008). Retrospective review alone was used in half of the hospitals, concurrent review or some mixed approach being used in the other half. Ontario and the Atlantic provinces were more reliant than the rest of the country on retrospective review alone (p = 0.0032). Most of the hospitals used peer review and education to stimulate corrective action. Of the respondents 67% indicated that the medical staff supported the utilization management program, and 53% reported that the program had a positive impact on the relationship between administrative and medical staff. Most of the respondents were unsure of the program's impact on the quality of care or the rate of unnecessary hospital admission. However, retrospective review alone was found to be less successful in reducing inappropriate utilization than either concurrent review or combined review (p = 0.0048).