Implications of managed care denials for pediatric inpatient care.
(1/400)
With the growing penetration of managed care into the healthcare market, providers continue to experience increasing cost constraints. In this environment, it is important to track reimbursement denials and understand the managed care organization's rationale for refusal of payment. This is especially critical for providers of pediatric care, as children justifiably have unique healthcare needs and utilization patterns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied claims primarily for one of three reasons: medically unnecessary care, care provided as a response to social (rather than medical) need, and provider inefficiencies. Health maintenance organization denials are also growing annually at our institutions. This knowledge can not only help providers of pediatric care more effectively negotiate future contracts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult. This information can be used as a basis for education, pediatric outcome studies, and guideline development--all tools that can help providers receive reasonable reimbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed. (+info)
Outcomes of routine testing of liver enzymes in institutionalized geriatric patients.
(2/400)
This study sought to identify any benefit of routine liver function tests (LFTs) in chronically ill, geriatric patients and to assess which patients require evaluation for abnormal LFT levels. A retrospective chart review was carried out on 268 consecutive patients (M:F = 1.2, mean age 77 years, range 61-98 years) presenting for acute care from a long-term care facility. All were without jaundice, right upper quadrant pain, pruritus, bruising, or signs of chronic liver disease. The degree of LFT abnormality (aspartate aminotransferase, alanine aminotransferase, total bilirubin, or alkaline phosphatase) during admission was compared to the clinical diagnosis at the time of discharge. The most common diagnoses were pneumonia, urinary tract infection, and peripheral or coronary disease in 186 (60%). Thirty-seven patients (14%) had elevated LFT levels on admission. The levels normalized within 2 days in 26 of these patients, 25 of whom had a history of vascular disease (96%). Of the 11 remaining patients, 4 had coexistent vascular disease (36%), and 5 had LFT levels twice normal (none with vascular disease) and underwent abdominal ultrasound. One patient had a common bile duct stone successfully extracted. Enzyme abnormalities were due to hepatitis B or medication use in 10 of 11 patients. No patient had liver biopsy. All but one of the 268 patients were discharged without further evaluation. Over one year of follow up, no patient returned for a liver-related problem. Based on these findings, only those patients with LFT levels that are twice normal and which do not normalize within 2 days warrant further evaluation. Transient LFT abnormalities may be due to decreased liver perfusion. (+info)
In vitro and skin testing for allergy: comparable clinical utility and costs.
(3/400)
Controversy exists concerning the appropriate use of skin testing and in vitro testing for the diagnosis of allergy, particularly inhalant allergy. Earlier comparisons of skin testing and in vitro testing concluded that skin testing had superior accuracy at lower expense. In light of new developments with in vitro allergy testing, however, this issue should be reconsidered. A review of the recent scientific literature indicates that in vitro and skin testing are highly correlated. However, without the existence of an independent gold standard for inhalant allergy, it is not possible to determine which test is more accurate. The accuracy of either test can be compromised if conducted using different protocols or having insufficient quality control. Given their respective trajectories for technological advancement, quantification, and quality control, in vitro testing may offer the more standardized approach. Although the cost per test of in vitro testing remains greater than that of skin testing, the per-patient costs of the two modalities appear to be comparable, given the greater number of allergens typically used in skin testing. In summary, both skin testing and in vitro testing are acceptable as frontline diagnostic tools. (+info)
Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group.
(4/400)
OBJECTIVE: To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES: Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS: Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS: Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated. (+info)
Observations on the misdiagnosis of generalized epilepsy as partial epilepsy: causes and consequences.
(5/400)
More therapeutic options (surgical and pharmacologic) are available for partial than for generalized epilepsies. This report describes and analyzes a possible bias to diagnose focal epilepsies. Data were prospectively collected on patients who underwent noninvasive prolonged EEG-video monitoring over a 2-year period at an epilepsy program. Cases where the diagnosis of 'partial seizures' (after monitoring) was questionable were identified and the data reviewed. Sixteen cases were identified. (a) Six had an idiopathic generalized epilepsy. All had generalized tonic-clonic (GTC) seizures, two had myoclonic seizures, and three had typical absences. All patients had generalized spikes and spike-wave complexes. All had normal IQs and normal brain imaging. One patient underwent invasive EEG. (b) Ten patients had a symptomatic or cryptogenic generalized epilepsy. IQs ranged from 49 to 74 (mean: 63). All patients had diffuse EEG slowing, and generalized ictal EEG patterns. Interictal EEG showed generalized spike-wave complexes in nine, and multifocal spikes in five. Seizures included GTC in all, generalized tonic in four, and atypical absences in two. Two of the 10 patients underwent invasive EEG. The misdiagnosis of generalized epilepsy as partial epilepsy occurs for both idiopathic and cryptogenic or symptomatic generalized epilepsies, more often in the latter case. Risk factors may include: asymmetry in EEG or seizure semeiology, the eagerness to enroll in drug studies or surgical programs, and the lack of team thinking involving several epileptologists. This problem is almost certainly under-reported and may occasionally result in unwarranted invasive procedures. (+info)
Pre-operative blood tests in children undergoing plastic surgery.
(6/400)
In a retrospective review of 1177 children presenting for plastic surgical procedures, investigations were performed in 487 and abnormal results were found in 138 as defined by variation from the local laboratory reference range. Most of the abnormalities were of no clinical significance. Twenty one children had abnormal haemoglobin results (the lowest was 9 g/dl) and 101 children had clinically insignificant platelet or white cell abnormalities. One child, with a family history of sickle cell trait, was confirmed as sickle-cell trait. No case was postponed as a result of these investigations. The non-selective ordering of pre-operative blood tests leads to unnecessary patient discomfort, the potential for additional superfluous investigations and higher costs. (+info)
Overuse and underuse of diagnostic upper gastrointestinal endoscopy in various clinical settings.
(7/400)
OBJECTIVES: To describe and compare both overuse and underuse of diagnostic upper gastrointestinal endoscopy in different settings. DESIGN: Merging of data from three prospective observational studies. The appropriateness and necessity of indications for gastroscopy were evaluated using explicit criteria developed by a standardized expert panel method (RAND-UCLA). Inappropriate endoscopies represent overuse. Necessary indications not referred for the procedure constitute underuse. SETTING: Three primary care outpatient clinics, 20 general practices, three gastroenterology practices, two district and one university hospitals. SUBJECTS: A third of the collective were consecutive ambulatory patients with upper abdominal complaints, whereas the other two thirds were ambulatory and hospitalized patients referred for the procedure. MAIN OUTCOME MEASURES: Proportions of overuse and underuse in the different settings. RESULTS: A total of 2885 patients were included (mean age, 49 years, 52% male, 2442 outpatients), 1858 patients underwent > or = 1 endoscopy. Among 2086 endoscopies, 805 (39%) were inappropriate, most of which were performed for dyspepsia (83%). Overuse was higher in young, foreign, female patients and lower in inpatient settings, the latter reflecting a different distribution of presenting symptoms. Among 1646 patient visits in primary care, overuse represented 148 endoscopies (9%). Underuse was identified in 104 of the same patient visits (6%) and was higher as patient age increased; there were no significant differences between men and women. CONCLUSIONS: Rates of overuse and underuse depend mainly on case presentation and patient characteristics. Both over- and underuse should be addressed to maintain and improve quality of care. (+info)
Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice.
(8/400)
OBJECTIVE: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus. SUBJECTS AND METHODS: Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses. RESULTS: The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence. CONCLUSION: The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available. (+info)