Effects of health care cost-containment programs on patterns of care and readmissions among children and adolescents.
OBJECTIVES: This study examined the effects of a utilization management program on patterns of medical care among children and adolescents. METHODS: From 1989 through 1993, the program conducted 8568 reviews of pediatric patients, ranging in age from birth to 18 years. The program used preadmission and concurrent review procedures to review and certify patients' need for care. This study used multivariate analyses to assess changes in the number of days of inpatient care approved by the program and to determine whether limitations imposed on length of stay affected the risk of 60-day readmission. RESULTS: Concurrent review reduced the number of requested days of inpatient care by 3.2 days per patient. Low-birthweight infants and adolescent patients with depression or alcohol or drug dependence accounted for a disproportionate share of the reduction. Patients classified as admitted for medical or mental health care and whose stay was restricted by concurrent review were more likely (P < .05) to be readmitted within 60 days after discharge. CONCLUSIONS: By limiting care through its review procedures, the utilization management program decreased inpatient resource consumption but also increased the risk of readmission for some patients. Continued investigation should be conducted of the effects of cost-containment programs on the quality of care given to children and adolescents, especially in the area of mental health. (+info)
The impact of utilization management on readmissions among patients with cardiovascular disease.
OBJECTIVE: To determine if prospective utilization reviews that lead to reduced hospital length of stay (LOS) relative to days requested by an attending physician affect the likelihood of readmission for privately insured patients with cardiovascular disease. DATA SOURCES: Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews performed on patients with cardiovascular disease. STUDY DESIGN: We used proportional hazard analysis (Cox regression) to investigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and procedural admissions. PRINCIPAL FINDINGS: There were 2,813 requests for medical admission, and 1,513 requests for procedural admission. Requests for admission were rarely denied. Length of stay was reduced relative to that requested by the treating physician for 17 percent and 19 percent of medical and procedural admissions, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for medical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be readmitted within 60 days as those who had no reduction in their length of stay (95% CI: 1.3-5.1; p < .005). CONCLUSIONS: Utilization management (UM) rarely denies requests for inpatient treatment of cardiovascular disease. The association between LOS reduction and the likelihood of readmission for patients admitted for cardiovascular procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and quality of care. (+info)
Underutilization of acute care settings in a tertiary care hospital.
OBJECTIVE: To estimate underutilization of acute care settings in a tertiary care hospital. DESIGN: A retrospective and concurrent cohort study using chart reviews and the Intensity of service, Severity of illness, Discharge screen for Acute Care (ISD-AC(R)) tool to measure appropriateness of acute care for patients who were receiving care in a less acute setting, as an indicator of underutilization. SETTING: A 450-bed tertiary care teaching hospital. STUDY PARTICIPANTS: Patients discharged from the emergency department, patients discharged from acute care inpatient units and patients in acute, non-critical care settings. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The percentage of patients discharged from the emergency department who did not meet the criteria for acute care discharge screens; the percentage of patients discharged from an acute care inpatient unit who did not meet the criteria for discharge screens; and the percentage of patients who were in acute, non-critical care beds and who met the criteria for critical care. RESULTS: It was found that six out of 168 patients [3.57%; 95% confidence interval (CI), 1.32-7.61%] did not meet the discharge screens at the time of discharge from the emergency department. Four out of 156 patients (2.56%; 95% CI, 0.70-6.43%) did not meet the discharge screens at the time of discharge from an acute care inpatient service and two out of 156 acute care patients (1.33%; 95% CI, 0.02-4.73%) who were in non-critical care beds met the criteria for critical care. CONCLUSION: These findings of underutilization may help to quantitate an unmet need in health care. (+info)
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. (+info)
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. (+info)
Methodology to improve data quality from chart review in the managed care setting.
BACKGROUND: Because inherent variability may exist in data collected by multiple reviewers or from potential difficulties with data abstraction tools, we developed a standardized method of evaluating interrater reliability (IRR) for clinical studies, HEDIS effectiveness of care measures, and onsite/medical record reviews. OBJECTIVE: To demonstrate the ability of our standardized methods of data collection and analysis of results to determine the extent of agreement between multiple reviewers; identify areas for improvement in data collection procedures; and improve data reliability. STUDY DESIGN: A prospective chart review with concurrent IRR. METHODS: A subsample of patient records included in the Highmark Blue Cross Blue Shield/Keystone Health Plan West basic medical review for each HEDIS measure was selected for the IRR study. An experienced nurse ("gold standard") conducted a blinded concurrent review of these records. Using the kappa statistic (kappa) we evaluated interobserver agreement between results of the onsite reviewers and the "gold standard" from 1997 through 2000. Revised data collection methods and enhanced reviewer training were incorporated for measures showing areas for rater improvement. RESULTS: Results across years showed excellent IRR for most measures; however, each year 1 or 2 measures showed areas for rater improvement (1997 Papanicolaou kappa = 0.50; 1998 well-child visits 3 to 6 years kappa = 0.37; 1999 comprehensive diabetes kappa = 0.73; high blood pressure kappa = 0.73). After reevaluating these measures, the results of the kappa showed excellent interrater agreement in subsequent years. CONCLUSIONS: Standardized methods of data collection and evaluation of IRR results provides health plans increased confidence in data collection, statistical analyses, and in reaching conclusions and deriving relevant recommendations. (+info)
Diagnostic cost groups (DCGs) and concurrent utilization among patients with substance abuse disorders.
OBJECTIVE: To assess the performance of Diagnostic Cost Groups (DCGs) in explaining variation in concurrent utilization for a defined subgroup, patients with substance abuse (SA) disorders, within the Department of Veterans Affairs (VA). DATA SOURCES: A 60 percent random sample of veterans who used health care services during Fiscal Year (FY) 1997 was obtained from VA administrative databases. Patients with SA disorders (13.3 percent) were identified from primary and secondary ICD-9-CM diagnosis codes. STUDY DESIGN: Concurrent risk adjustment models were fitted and tested using the DCG/HCC model. Three outcome measures were defined: (1) "service days" (the sum of a patient's inpatient and outpatient visit days), (2) mental health/substance abuse (MH/SA) service days, and (3) ambulatory provider encounters. To improve model performance, we ran three DCG/HCC models with additional indicators for patients with SA disorders. DATA COLLECTION: To create a single file of veterans who used health care services in FY 1997, we merged records from all VA inpatient and outpatient files. PRINCIPAL FINDINGS: Adding indicators for patients with mild/moderate SA disorders did not appreciably improve the R-squares for any of the outcome measures. When indicators were added for patients with severe SA who were in the most costly category, the explanatory ability of the models was modestly improved for all three outcomes. CONCLUSIONS: Modifying the DCG/HCC model with additional markers for SA modestly improved homogeneity and model prediction. Because considerable variation still remained after modeling, we conclude that health care systems should evaluate "off-the-shelf" risk adjustment systems before applying them to their own populations. (+info)
Profiling resource use: do different outcomes affect assessments of provider efficiency?
OBJECTIVES: To examine whether 2 outcome measures result in different assessments of efficiency across 22 service networks within the Department of Veterans Affairs (VA). STUDY DESIGN: A retrospective analysis using VA inpatient and outpatient administrative databases. METHODS: A 60% random sample of veterans who used healthcare services during fiscal year 1997 was split into a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Weighted concurrent case-mix models using adjusted clinical groups were developed to explain variation in 2 outcomes: "days of care"--the sum of a patient's inpatient and outpatient annual visit days, and "average accounting costs"--the sum of the average service costs multiplied by the units of service for each patient. Two profiling indicators were calculated for each outcome: an unadjusted efficiency index and an adjusted efficiency index. These indices were compared to examine network efficiency. RESULTS: Although about half the networks were identified as "efficient" before and after case-mix adjustment, assessments of individual network efficiency were affected by the adjustment. The 2 outcomes differed on which networks were efficient. For example, 4 networks that appeared as efficient based on days of care appeared as inefficient based on average costs. CONCLUSIONS: Assessments of provider efficiency across the 22 networks depended on the outcome measure used. Knowledge about the extent to which assessments of provider efficiency depend on the outcome measure used is an important step toward improved and more equitable comparisons across providers. (+info)