Hospital case management and the Utilization Review Committee.

PURPOSE/OBJECTIVES: This article describes the overall regulatory mandate governing the Utilization Review Committee (URC) in the hospital setting. General structure, function, and meeting format of the URC are important considerations. Furthermore, the URC can serve as a vital platform for medical staff leadership and case management practice to use pertinent risk-adjusted data to drive needed change at the organizational, departmental, service line, and physician level. A case history illustrates the importance of these issues. PRIMARY PRACTICE SETTING: Acute care hospitals. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Case management staff, medical advisors, and physician leaders play important roles in driving changes. The URC will become ever-more important in the rapidly accelerating changes, driving heightened accountability on the part of hospitals.

[Appropriateness of hospitalization in a ward of internal medicine--using the Appropriateness Evaluation Protocol]. / Adequação do internamento num serviço de medicina interna. Utilizando o Appropriateness Evaluation Protocol.

INTRODUCTION: The Appropriateness Evaluation Protocol (AEP) is an instrument to study the appropriate use of hospital beds based in objective criteria that classify a hospital admission as appropriate or inappropriate. OBJECT: Evaluate the appropriateness of hospital admissions and stays of the patients of our Internal Medicine Department using the concurrent version of AEP. METHOD: Transversal study where was evaluated the clinical record of the patients admitted to our Department of Internal Medicine on March 13th of 2003, excluding all these who were admitted the day of the study. We analyzed demographic and clinic parameters and the appropriateness of hospital admission and stay using the AEP. RESULTS: 22 patients fulfilled the inclusion criteria, 54.5% of male gender with a average age of 70.7 years. All the admissions were considered appropriate. The most common criteria was the need of intravenous therapy (100%), followed by the sudden lost of corporal mobility (12.3%). 27.3% of stays were considered inappropriate on the day of the study. The most common criteria of appropriateness was the need of intravenous therapy (93.7%). The most usual reason of inappropriate stay was the existence of planned discharge, but without the order written down in the clinical file (66.7%). CONCLUSIONS: The AEP allows an efficient evaluation of the appropriateness of the hospital admissions and stays in a Health Unit, being used for a better utilization of resources. In our department all admissions were justified and about a quarter of stays were considered inappropriate using the AEP.

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

BACKGROUND: Adverse events (AEs) occur with alarming frequency in health care and can have a significant impact on both patients and caregivers. There is a pressing need to understand better the frequency, nature, and etiology of AEs, but currently available methodologies to identify AEs have significant limitations. We hypothesized that it would be possible to design a method to conduct real time active surveillance and conducted a pilot study to identify adverse events and medical errors. METHODS: Records were selected based on 21 electronically obtained triggers, including abnormal laboratory values and high risk and antidote medications. Triggers were chosen based on their expected potential to signal AEs occurring during hospital admissions. Each AE was rated for preventability and severity and categorized by type of event. Reviews were performed by an interdisciplinary patient safety team. RESULTS: Over a 3 month period 327 medical records were reviewed; at least one AE or medical error was identified in 243 (74%). There were 163 preventable AEs (events in which there was a medical error that resulted in patient harm) and 138 medical errors that did not lead to patient harm. Interventions to prevent or ameliorate harm were made following review of the medical records of 47 patients. CONCLUSIONS: This methodology of active surveillance allows for the identification and assessment of adverse events among hospitalized patients. It provides a unique opportunity to review events at or near the time of their occurrence and to intervene and prevent harm.

ED diversions reduced by tight monitoring.

Hospital had no good system for measuring flow through the organization. Mechanism to ensure action is a key element in program's success. Giving nurses greater control drops staff vacancy rates and boosts satisfaction.

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.

Metric properties of the appropriateness evaluation protocol and predictors of inappropriate hospital use in Germany: an approach using longitudinal patient data.

BACKGROUND: The German health care system, renowned for its unrestricted access, high quality care, and comprehensive coverage, is challenged by increasing health care costs. This has been attributed partly to inefficiencies in the in-patient sector, but has been studied little. Attempts at quality improvement need to relate costs to outcomes. Until now, there has been no standardized methodology to evaluate the appropriateness of hospital care. OBJECTIVE: To develop and evaluate the metric properties of a method to assess inappropriate hospital care in Germany based on a widely used measure, the Appropriateness Evaluation Protocol (AEP). METHODS: The original AEP was translated and adapted to reflect differences in the provision of health care in Germany. Psychometric testing was performed in a stratified sample of all patients admitted to the Departments of Medicine and Surgery of a 400-bed teaching hospital during 1 year. Three board-certified physicians participated in each department to evaluate intra-rater reliability, while two additional independent physicians judged inter-rater reliability. RESULTS: Inter-rater agreement for the evaluation of hospital days among surgical patients was 84% (80-87%), with an average kappa value of 0.58 (0.48-0.68). Corresponding figures for patients in medicine were 76% (73-80%) with a K value of 0.42 (0.34-0.42). Inter-rater agreement for hospital admissions and K was 74% (62-86%) and 0.44 (0.21-0.67) in surgery, and 92% (85-100%) and 0.31 (0-0.80) in medicine, respectively. Thirty-three per cent of all admissions and 28% of consecutive hospital days were judged inappropriate in surgery; among medicine patients, reviewers found 6% of admissions and 33% of hospital days inappropriate. Time since admission was the strongest predictor of inappropriate hospital use adjusted for length of stay, comorbidity, age, and gender.

[Cause of non-pertinent hospital stays: interobserver concordance using the French version of the Appropriateness Evaluation Protocol]. / Etude de la concordance inter-observateurs des raisons de non-pertinence des journées d'hospitalisation identifiée par la version française de l'Appropriateness Evaluation Protocol (2e partie).

BACKGROUND: The modified French version of the Appropriateness Evaluation Protocol (AEPf) has been validated. Inappropriate days according to simple medical and technical criteria are identified with this tool. The aim of this study is to highlight the interest of investigating the reasons for inappropriate days and to assess the inter-observers reliability of the questionnaire developed for this purpose. METHODS: This questionnaire collects on one hand the needs of patients - distinguishing health care and accommodation needs - and on the other hand the reasons for inappropriate hospital days. The data were collected from January to September 1998 in nine voluntary medical and surgical departments. For each day of study randomly selected, each inappropriate hospital day according to AEPf has been included. Data were collected by two health professionals (a nurse and a physician), using a concurrent design. RESULTS: The reliability of the over-ride option of the appropriateness assessment of the 345 hospital days was good (overall Kappa coefficient: 0.66; 95% CI: 0.55-0.78). The comparison of the two expert judgments on health care needs fulfilled during the hospital day was acceptable; the Kappa coefficient was 0.62 (95% CI: 0.52-0.72). The reliability of expert assessment on patient accommodation needs (home, housing facilities or hospital) was good (Kappa coefficient: 0.67; 95% CI: 0.60-0.75). When hospital was not the accommodation the most adapted for patient, the reliability of the reasons for inappropriate days was high (Kappa coefficient: 0.75; 95% CI: 0.61-0.80). Kappa coefficients were different between hospitals, indicating a center effect. CONCLUSION: This instrument has been found to be reliable and should be used in complement of the first part of the AEPf which assess the prevalence of inappropriate days. It might help to detect dysfunctions within or outside the hospital and thus be used for evaluation or planning of health care.

CONTINUUM-Activity Index: managing admission inappropriate stays in a community hospital.

The CONTINUUM-Activity Index was used as a concurrent tool to measure intensity of services delivered in an Acute Care Community Hospital. Applying these specific daily measures identified patients who did not meet admission-appropriateness criteria on the first day of care or did not meet those criteria on two days subsequent to admission. These patients had a high probability that their entire stay would be inappropriate. Action was then taken to move the care process forward, resulting in a significant reduction in inappropriate hospital days.

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.

Implementing a computer-assisted appropriateness review using DRG 182/183.

BACKGROUND: The focus on patient outcomes as performance measures and on processes of care as systems to improve is intensifying. Nevertheless, appropriateness reviews are likely to remain essential (for example, studies evaluating inpatient admission, laboratory testing, invasive procedures, and discharge planning) for several reasons. METHODS: Forbes Regional Hospital (Monroeville, PA) undertook to redesign the process of appropriateness reviews using a computer-assisted methodology. The change was predicated on accessing electronically recorded clinical data collected as part of a state-mandated discharge reporting requirement. RESULTS: More than 90% of diagnosis-related group 182/183 (gastrointestinal/esophagitis) admissions were deemed appropriate on the basis of later manual reviews. This redesign was accomplished at no added expense while the amount of time required to complete the study was decreased. The ability to easily examine relationships identified during the evaluation was also expanded. The experience led to greater enthusiasm on the part of the medical staff to pursue more quality improvement projects. Creation of software programs that can be used repeatedly, modified to change existing thresholds, or expanded to include other conditions was another benefit. Clinicians gained valuable experience and familiarity with information systems. Lastly, all this was accomplished without purchasing new hardware, acquiring updated software, or relying on the presence of an electronic medical record.

Computerized decision support for concurrent utilization review using the HELP system.

OBJECTIVE: Development and evaluation of computerized concurrent utilization review (UR) support taking advantage of a clinically rich computerized patient database. DESIGN: The Automated Support System for Utilization Review (ASSURE) applies the Appropriateness Evaluation Protocol (AEP) Day of Care criteria to computerized patient data in the HELP hospital information system. This paper reports the development, verification, and validation of ASSURE. MEASUREMENTS: Implementation correctness was verified by measuring agreement with a nurse reviewer, using separate sample sets for all 20 criteria for a total of 560 current inpatients. Usefulness in detecting inappropriate days of care was validated by two nurse reviewers who were crossed with manual and computer-assisted review methods in a blocked design for 168 current inpatients. Agreement with reviewers, sensitivity, specificity, positive predictive value, and negative predictive value were measured. RESULTS: Agreement was very good for satisfaction of criteria, and good for appropriateness of day of care. A patient day identified by ASSURE as potentially inappropriate would be twice as likely to be judged inappropriate by a reviewer as a randomly selected patient day. Review of the 10% of patient days identified as potentially inappropriate by ASSURE would identify approximately 21% of the inappropriate days of care. CONCLUSION: ASSURE is a clinically useful tool for screening adult acute care patients for inappropriate days of care, and promises to make a major contribution to reducing health care costs. The prognosis for successful routine clinical use is good.

Pre-billing DRG reviews set new standard.

When and how you do DRG review is critical. This piece offers tips on hiring consultants who can help you provide this financially important service.

Inspection of care: findings from an innovative demonstration.

In this article, information is presented concerning the efficacy of a sample-based approach to completing inspection of care reviews of Medicaid-supported nursing home residents. Massachusetts nursing homes were randomly assigned to full (the control group) or sample (the experimental group) review conditions. The primary research focus was to determine whether the proportion of facilities found to be deficient (based on quality of care and level of care criteria) in the experimental sample was comparable to the proportion in the control sample. The findings supported such a hypothesis: Deficient facilities appear to be equally identifiable using the random or full-sampling protocols, and the process can be completed with a considerable savings of surveyor time.

Concurrent chart analysis and DRG assignment in a prospective payment environment.

Medicare's prospective payment system and the elimination of periodic interim payments have caused dramatic changes in the day-to-day operations of most medical record departments. This article discusses one method to help hospitals expedite record completion and bill in a more timely fashion.

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient's age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient's discharge and less than one third of patients had been given more than 24 hours' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.

The development and implementation of a drug utilization review program.

In response to rising drug expenditures and pressure from hospital administration to contain drug costs, the department of pharmaceutical services at The Mississauga Hospital initiated a Drug Utilization Review (DUR) Program. The main purpose of this program was to contain the escalating drug budget through identifying and correcting areas of drug misuse, without compromising the quality of patient care. This article will describe the procedures involved in developing and implementing such a DUR program at our hospital and our experience to date. Both structured and informal strategies have been implemented, which have identified factual and potential cost savings. Overall, the DUR program has been well accepted by the medical staff and hospital administration.