Evaluating the Effectiveness of Concurrent Review: Does It Improve Stroke Measure Results?

BACKGROUND: Concurrent review is a quality improvement strategy in which patients are tracked from admission to discharge, and messages are communicated to the responsible physician when quality stroke measures have not been met. There is little research regarding interventions that might influence clinical practice patterns and improvement in compliance with core quality measures. This study sought to evaluate whether concurrent review implementation was associated with change in performance on stroke measure outcome data. METHODS: Randomly selected charts from 2 hospitals (A and B) during 3 time periods were reviewed. In period 1, neither hospital had a process for concurrent review. In period 2, hospital A, where concurrent review was implemented, was compared with hospital B without this process. In period 3, both hospitals had the process of concurrent review. Information on baseline demographics, insurance status, and length of stay was collected, as well as stroke performance measures. RESULTS: A total of 620 medical records were reviewed during the 3 time periods. Although the number of beds and annual stroke volume were higher at hospital B, patient characteristics were similar. During period 2, when hospital A implemented concurrent review and hospital B had not, a statistically significant higher compliance with performance in 7 stroke measures occurred in hospital A than in hospital B. In period 3, when both hospitals utilized concurrent review, no statistical significant differences occurred in 7 of the 10 stroke measures. CONCLUSION: Concurrent review is a quality improvement intervention that increases performance with stroke performance measures.

Substitution of hospital staff in concurrent utilization review.

Substitution of hospital staff performing concurrent utilization review (CUR) was evaluated using a production process framework. There were no differences in the number of reimbursement denials or denied days among 4 job classifications of hospital staff performing CUR, indicating that educational preparation of staff did not affect outcomes. The implications are that hospitals could substitute assistive staff in place of registered nurses to complete the CUR function, potentially increasing the availability of professional nurses.

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.

Improving physician documentation through a clinical documentation management program.

Improving physician documentation ensures that the patient's clinical course is clearly recorded. North Carolina Baptist Hospital implemented interventions addressing physician documentation to ensure the assignment of the most appropriate diagnosis-related group (DRG) when it launched the Clinical Documentation Management Program (CDMP). Collaboration between registered nurses trained as clinical documentation consultants (CDC) and certified coding specialists as well as ongoing physician education has resulted in more accurate and complete documentation in the medical record.

Back to the drawing board: new directions in health plans' care management strategies.

The backlash against managed care has pressured health plans to reexamine their approaches to controlling utilization and managing their members' health care needs, but how much has really changed? Interviews with health plans and others in twelve nationally representative markets suggest that the changes are significant. New and refined disease management programs are improving the care experience of participants with certain prevalent chronic illnesses, while utilization management changes are reducing the administrative burden for providers. Still, disease management programs will need to greatly expand in scope and scale if plans are to succeed in addressing the complex health care needs of aging populations and those with chronic diseases.

Effects of utilization management on patterns of hospital care among privately insured adult patients.

OBJECTIVES: This study examined the effects of utilization management review activities on patterns of hospital care among a sample of adult patients insured through a managed fee-for-service plan. METHODS: The study was a retrospective analysis of insurance administrative data representing a case series of patients for whom utilization management review was performed. Two review activities were analyzed: pre-admission review and concurrent (continued stay) review. Patients were 49,654 privately insured adult patients reviewed for care between January 1989 and December 1993. Review outcomes included inpatient or outpatient care denied, site of treatment shifted (from inpatient to outpatient), or reduction in requested hospital days (total days requested - total days approved). RESULTS: Few patients (<1%) were denied care at time of admission or were required to obtain outpatient instead of inpatient care. More common was action taken to limit length of stay by concurrent review, which accounted for 83% of the total reduction (25,197 requested days) in inpatient care. Utilization management became more restrictive with time: the number of days approved declined by 15% to 50% from 1990 to 1993, depending on the type of admission. Utilization management was most forceful in restricting care for mental health patients, who represented 5.7% of the study population but accounted for 54.7% of the total reduction in requested days. CONCLUSIONS: The utilization management program appeared to limit hospital care by managing length of stay once patients were admitted. The effects of restricting length of stay in this manner on quality and health outcomes should be investigated.

Appropriateness of admissions: the French experience.

The French studies using the Appropriateness Evaluation Protocol (AEP) were developed within the framework of medical audit by local teams, analysing their own practice, in order to improve the quality of care. Four studies were analysed in this review. They were performed in emergency departments and data were collected concurrently. The reliability and validity of this French version of the AEP was assessed. The high reliability of the AEP was found to be useful to measure trends or differences between groups. The percentages of inappropriate admissions observed in the studies ranged from 18 to 25%. The hypothesis that the rate of inappropriate admissions would be highest among the elderly was not confirmed in Paris. Homelessness was the only social factor related to a high rate of inappropriate admissions in three of the studies. In one study, age and lack of social support were found to be risk factors for inappropriate admissions. The study of the causes of inappropriate admissions was important, since they were to be used as an indicator of systemic problems in the organization of health care delivery. A distinction was made between appropriate and justified admissions on both a systemic and an individual level. In conclusion, AEP was found to be an indicator that was both reliable and useful to identify quality of care problems. Among the factors found to be related to inappropriate admissions, the internal organization of the hospital proved to be one of the main reasons and a target for improvement.

CONTINUUM: measuring and managing the patient care process.

The authors describe the CONTINUUM project which was initiated in a community hospital to manage the appropriateness, timeliness and acceptability of the patient care process on a concurrent or day-to-day basis. CONTINUUM is a quality and data-driven approach to continuous improvement of the patient care process. The St. Thomas-Elgin General Hospital researched "appropriateness of care" measurements and adapted their use for the CONTINUUM project. A concurrent care plan evaluation tool is applied to every care every day. This intensity of service (needs-based) strategy is called the ACTIVITY index. Patients are categorized ACTIV (appropriate) or non-ACTIV (perhaps inappropriate). Non-ACTIV patients are further subdivided into various "barriers to care," from which service, hospital or physician-related factors can be stratified. Practice patterns and hospital resource use are then rapidly identified. The operational dimensions of the project (bedside, organization and community) are described as well as the inhibitors and enablers of this change process.

A concurrent cefuroxime use evaluation in pediatric patients.

A concurrent evaluation of cefuroxime use in pediatric patients is described. From March 5, 1991 to May 15, 1991, the use of cefuroxime in pediatric patients was evaluated. The pediatric liaison pharmacist collected clinical information about each patient prescribed cefuroxime and assessed the therapy according to pre-established criteria for use. When therapy did not meet criteria, the pharmacist could intervene by speaking with the prescribing physician. The Coordinator, Drug Use Evaluation (D.U.E.) Program and a pediatrician, reviewed the data collection forms to assess whether therapy met criteria and the outcome of pharmacist-physician interactions. Thirty-five pediatric patients were prescribed cefuroxime during the concurrent evaluation. All courses were empiric. Community-acquired pneumonia accounted for 21 treatment courses in which cefuroxime was prescribed with 18 of these deemed to meet the criteria. It was also prescribed empirically in otitis media (eight cases), meningitis (two cases). Overall, seventy-seven percent of therapeutic courses of cefuroxime were found to meet established criteria for use. The pediatric clinical pharmacist intervened in six therapeutic courses which did not meet criteria. Three of these interventions resulted in a change of therapy for the patient.

Computer-assisted use of tracer antidote drugs to increase detection of adverse drug reactions: a retrospective and concurrent trial.

The authors found that a concurrent review of use of antidote drugs commonly used for the treatment of adverse drug reactions is an effective method for identifying such reactions. Computer-assisted detection helped rule out false-positives and decrease the number charts to be screened, thereby reducing the time needed to find adverse drug reactions.

Hospital mainframe computer documentation of pharmacist interventions.

The hospital mainframe computer pharmacist intervention documentation system described has successfully facilitated the recording, communication, analysis, and reporting of interventions at our hospital. It has proven to be time efficient, accessible, and user-friendly from the standpoint of both the pharmacist and administrator. The advantages of this system greatly outweigh manual documentation and justify the initial time investment in its design and development. In the future, it is hoped that the system can have even broader impact. Intervention/recommendations documented can be made accessible to medical and nursing staff, and as such further increase interdepartmental communication. As pharmacists embrace the pharmaceutical care mandate, documenting interventions in patient care will continue to grow in importance. Complete documentation is essential if pharmacists are to assume responsibility for patient outcomes. With time being an ever-increasing premium, and with economic and human resources dwindling, an efficient and effective means of recording and tracking pharmacist interventions will become imperative for survival in the fiscally challenged health care arena. Documentation of pharmacist intervention using a hospital mainframe computer at UIH has proven both efficient and effective.

Interventions: a quality assessment tool for the pharmacy department and the medical staff.

The intervention tracking system at Texas Children's Hospital has evolved from a simple log to a pocket book of check-off forms requiring minimal writing. Information gathered from the intervention data has progressed from merely notification that a call was made to tracking numbers and types of interventions to including the pharmacists in the information loop. Pharmacists are assured that the time spent documenting interventions provides data for medical staff QI, pharmacy QI, and feedback to themselves as well. No documentation is wasted; no separate data collection is required. Intervention categories with medical staff-approved indicators are treated as a concurrent DUE. Depending on the rate of acceptance of pharmacists' recommendations, physicians, pharmacists, or both are targeted for education. Analysis of the acceptance rate may also indicate the need for systems changes more profoundly affecting one or the other of the groups.