Use Of Ancillary Services Research Articles

Vascular surgeons' resource use at a university hospital related to diagnostic-related group and source of admission.

To determine whether differences in the conduct of individual practices of attending vascular surgeons account for variations in resource use at a university hospital. The practice patterns of six attending vascular surgeons at the University of Michigan Hospital were assessed for patient length of stay (LOS), ancillary service use, and the number of nursing hours required. Included in the study were 1930 hospitalized patients who had one of the 10 most frequently encountered diagnostic related groups (DRGs). Statistical analyses of variables that were thought likely to affect resource use included multiple regression models. Patient age, sex, insurance, source of admission (direct admission or transfer admission), surgeon, and DRG category together accounted for 22% of LOS variation, 27.7% of variation in ancillary service use, and 29.4% of variation in nursing hours. In no model did the individual surgeon's practice significantly effect the LOS, ancillary use, or nursing hours. Patients transferred from other hospitals had increased resource use in all models. The DRG category alone explained 20.9% of the variance in LOS, 25.2% of the variation in ancillary service use, and 21.2% of the variance in nursing hours. Differences in the conduct of individual vascular surgeons' practices accounted for less than 1% variation in hospital resource use. The most important influences on resource use were the DRG category and the source of patient admission. Modification of the frequency and manner of accepting transfer patients to vascular surgery services of a university hospital may have a major impact on hospital resource use.

Comparing the hospitalizations of transfer and non-transfer patients in an academic medical center

By accepting and caring for patients transferred from other institutions, academic medical centers have been able to develop comprehensive training and research programs. Whether academic institutions can continue to do this in the future is questionable. To the extent that transfer patients are more complex and severely ill than non-transfer patients, they are likely to consume more resources, and in managed care payment systems, they could place accepting hospitals in financial jeopardy. Between July 1989 and December 1993, the internal medicine, surgery, and pediatrics services of the 880-bed University Hospital of the University of Michigan accepted 8,740 patients from other hospitals. The hospitalizations of these patients were compared with those of the 76,047 non-transfer patients on these services. The statistical methods used were Student's t-test, chi-square, Cochran-Mantel-Haenszel chi-square, and analysis of variance. The hospitalizations of the transfer patients were more complex and resource-use intensive. The transfer patients were more likely (p<.0000) to be length-of-stay outliers as defined by Medicare standards (28% vs 10%) and to suffer in-hospital death (9.4% vs 2.5%). After case-mix adjustment and exclusion of length-of-stay outliers, transfer patients on the three services (surgery, medicine, and pediatrics) remained in the hospital 1.62, 1.15, and 0.84 days longer (p<.0001) than non-transfer patients. Ancillary-service resource use was assessed using a relative-value-unit (RVU) scale based on direct-cost dollars. The transfer patients' case-mix-adjusted resource use exceeded that of the non-transfer patients by 1,155,850 and 957 RVUs for surgery, pediatrics, and medicine (p<.0001). Although the transfer patients were more likely to have Medicaid insurance, the differences in lengths of stay and use of ancillary services persisted throughout all insurance groups. Indeed, transfer status, compared with age, sex, and insurance status, was the best predictor of high resource use. The transfer patients stayed longer and consumed more hospital resources than did the non-transfer patients. Age, sex, case-mix, and insurance status did not account for these differences. To limit the financial liability that transfer patients pose, academic medical centers could be forced to abandon their traditional role of caring for such patients. The consequences of this possibility should be explored.

The Integrated Inpatient Management Model

The Integrated Inpatient Management Model was a 2.5-year controlled prospective trial of using a clinical information system to direct and monitor physician and hospital practice on general medicine services of an 880-bed university hospital. For the over 2,000 admissions on both a control service and the intervention service, the mean length of stay (LOS) decreased when compared with historic norms (0.68 and 0.95 days respectively; P < 0.01 for both). This difference in mean LOS represents a savings of 580 hospital days for the intervention over the control service; (95% confidence interval, 300 to 1420 days). There also was a trend for the intervention service to have fewer LOS outliers than expected (P = 0.14). Ancillary service use decreased by 17% on both control and intervention services (a trend that disappeared after the study was terminated), while other internal medicine services experienced a 29% increase in this measure of resource use. The intervention service experienced fewer preventable deaths (P = 0.04), but there were no differences in global quality of care measures, readmission and mortality rates, and patient satisfaction. This use of a clinical information system is a prototype for the systems that will be needed for all forms of managed care.

Is ondansetron cost effective?

5-Hydroxytryptamine3 (5-HT3) receptor antagonists are a major breakthrough in the prevention of nausea and vomiting induced by cancer chemotherapy. The acquisition cost of these drugs is considerably higher than for more conventional antiemetics. In this study, the authors reported on the economic consequences of giving ondansetron in Thomas Jefferson University Hospital, Philadelphia, USA. The study was divided into 3 parts. The first part was retrospective, and had the primary aim of comparing lengths of hospital stay and overall hospital costs for patients who had received intravenous ondansetron or standard antiemetic therapy. The purpose of the second part, which was prospective, was to determine the cost of emesis. In the third part, quality of life was studied; however, the results of this part were difficult to interpret because only 27 of the 52 selected patients completed the questionnaire, and only 4 of these patients received standard antiemetic therapy. In the retrospective study, costs were evaluated for patients who never received ondansetron, those who always received it, and those who received ondansetron during at least 1 hospital stay. In the prospective study, the costs associated with vomiting were nursing time, time required to obtain antiemetic therapy from the pharmacy, telephone calls to contact physicians, additional use of ancillary services, and laundry costs for soiled items. In the retrospective analysis, it was found that the average length of hospital stay for patients who were always given ondansetron was significantly shorter than for those who never received it.(ABSTRACT TRUNCATED AT 250 WORDS)

The Financial Benefits of an Effective Hospitalwide Quality Assurance/Utilization Management Program

This article describes the organizational structure and functions of the quality assurance/utilization management (QA/UM) department at The Johns Hopkins Hospital (Baltimore), which has developed a proactive QA/UM program for identifying opportunities to control inappropriate inpatient admissions, shorten a patient's length of stay, monitor the use of ancillary services, and improve physician documentation in patient medical records. In addition, the QA/UM department has developed and implemented an aggressive third-party appeal mechanism to ensure that the institution has an effective UM program. The QA/UM department annually recovers more than 3 million dollars for the hospital by aggressively appealing third-party payer denials. Specific chart-review variables are outlined.

Substituting Diagnostic Services

Hospitals' patterns of ancillary service use were examined to determine whether new technologies replace older, more outmoded technologies, and to explore the factors associated with adoption of newer services and abandonment of older services. Annual inpatient use of five pairs of ancillary services was measured for 1978 through 1980 at 63 hospitals in five regions. The diagnostic test pairs consisted of one well-established diagnostic test and one newer service that could largely substitute for the older one and included (1) oral cholecystogram and gallbladder ultrasound; (2) brain scan and computed tomographic head scan; (3) skull roentgenogram and brain scan; (4) bone survey and bone scan; and (5) blood type/cross and type/screen. Use of gallbladder ultrasound increased significantly after its adoption, with small decreases in the use of oral cholecystogram, its paired test. For the other newer tests examined, increased use was not accompanied by significantly decreased use of the paired older service. The strongest predictors of change in patterns of test use were hospital size, number of residencies, occupancy, urban location, and the proportion of specialists on staff. We conclude that diffusion of new diagnostic services occurs gradually and often without concomitant decrease in older, outmoded services; new services generally seem to complement rather than substitute for older ones. Larger hospitals with a greater teaching commitment make a faster transition to the use of new technologies and the abandonment of older ones.

Racial differences in health care utilization among children in foster care

Health services utilization patterns of foster children in Baltimore City, MD are described and health services utilization is compared between black and white foster children. Utilization data were obtained on a sample of 417 children receiving health service payments through the Maryland Medical Assistance program and data cover one year for all children. Black and white children were found to have similar family, and health status characteristics. The total sample had a mean number of 4.6 outpatient visits during the study year with 16.8% having no health care utilization. White children had significantly more mean visits overall (7.1) than did black children (3.9), significantly higher utilization when examined by provider type or reason for visit, and a significantly higher use of ancillary services. A larger proportion of black children had no utilization during the study period. Possible explanations and policy implications of these results are discussed.

Ethical issues in the use of a prospective payment system: the issue of a severity of illness adjustment.

The current Medicare prospective payment system has many positive incentives for hospitals to control costs. Hospitals are increasing outpatient surgery, decreasing admissions, decreasing length of stay, and decreasing use of ancillary services. These are just the effects that Congress and the Health Care Financing Administration hoped for to save the Medicare trust fund. However, there has been evidence of some adverse outcomes including premature discharge, "dumping" sicker patients and patients without insurance, and adverse impact on hospitals with specialty centers. We examine these issues and present a possible solution based on a new Computerized Severity Index.

Prospective-pricing strategies for hospital and departmental effectiveness: The physician's response

Strategies a pharmacy department used to identify product costs and cost of drug therapy by case type are discussed. To define its intermediate products, the pharmacy identified 300 of 7500 line items on the formulary as representing 95% of its drug costs. This information, coupled with workload measures and component costs such as labor and supplies, was used to identify the cost of the pharmacy's products. A retrospective drug-therapy analysis conducted on total-hip-replacement procedures showed that drugs can be indicators of the severity of medical problems and hence good predictors of total hospital cost per case. Intermediate-product costing can be used to determine end-product profitability. Clinical pharmacists can help substantially in trying to determine the total cost of drug therapy, and they can help by developing standard treatment patterns with cost standards for treating patients in specific DRGs.

Prospective-pricing strategies for hospital and departmental effectiveness: The administrator's response

The approach of the New England Medical Center toward case management and increased productivity, and the role of the pharmacy within this system, are described by a chief hospital administrator. External pressures that caused the hospital to alter its management style included changes in reimbursement, hospital overuse, increased competition, and a surplus of physicians. Variations in medical practice that affected admission rates, length of stay, and use of ancillary services existed because clinical and financial data had not been integrated, so clinicians had no information on the economic consequences of their decisions. The solution offered to this problem was to decentralize resource-use decisions to increase clinician accountability. The goal of the case-management system is to reduce the cost of intermediate product (e.g., laboratory tests) use through increased productivity. The system provides pharmacy with a new power base if pharmacists can reduce overall costs by influencing prescribers to use cost-effective therapies. Pharmacy can increase its influence within the institution by forming new relationships with administrators, physicians, and nurses that broaden its impact on cost.

The Ancillary Services Review Program in Massachusetts

In 1982, a pilot program to review the use of ancillary services in 25 hospitals was implemented in Massachusetts. The program analyzed hospital claims data to generate statistical models of ancillary use. Hospitals where the model demonstrated substantially higher use were subjected to clinical review. For laboratory services, three of the four hospitals reviewed were found to have more than 30% inappropriate use of selected tests, compared with approximately 20% in other hospitals. For cardiac services, three hospitals were each found to have more than 30% inappropriate use of selected tests, compared with 16% in other hospitals. When informed of these results, five of the six hospitals used them to develop plans of corrective action. Based on the pilot program, a review of ancillary services began in all Massachusetts hospitals in 1983.

The Ancillary Services Review Program in Massachusetts. Experience of the 1982 pilot project

In 1982, a pilot program to review the use of ancillary services in 25 hospitals was implemented in Massachusetts. The program analyzed hospital claims data to generate statistical models of ancillary use. Hospitals where the model demonstrated substantially higher use were subjected to clinical review. For laboratory services, three of the four hospitals reviewed were found to have more than 30% inappropriate use of selected tests, compared with approximately 20% in other hospitals. For cardiac services, three hospitals were each found to have more than 30% inappropriate use of selected tests, compared with 16% in other hospitals. When informed of these results, five of the six hospitals used them to develop plans of corrective action. Based on the pilot program, a review of ancillary services began in all Massachusetts hospitals in 1983. (<i>JAMA</i>1984;252:1727-1732)

Utilization and costs of Medicare services by beneficiaries in their last year of life.

This study examines Medicare utilization in the last year of life by over 10,000 beneficiaries who died in the state of Colorado in 1978. Overall, Medicare use averaged over $6,000 in 1978, compared with use by a random sample of survivors of less than $1,000. Eighty-nine percent of the charges during the last year of life were for services received in a hospital. Average charges vary by entitlement status, with the aged using, on the average, $5,955, the disabled $7,771, and end-stage renal disease (ESRD) beneficiaries an average of $44,400 in their last year. These charges are more than six times greater than yearly charges for aged and disabled survivors and more than three times greater than the yearly charges for ESRD survivors. The distributions of data for the groups who died is highly skewed, but not as skewed as that for the survivors. The top 1% of the survivors consumed 21% of the total charges, compared with less than 9% total charges consumed by the top 1% of those who died. When the data are examined by date of service divided into quarterly periods in the last year, more than 60% of the expenditures are in the last quarter just before death, with more hospital days and more intensive hospital ancillary service use during this period.

Cost-effective Medical Care

To the Editor.— The recent editorial by Lundberg concerning overuse of laboratory tests was interesting and appropriate in light of the ever-increasing cost of health care (1983; 249:639). We have previously reported on a comparison of laboratory and ancillary service use between endocrinologists and nonendocrinologists treating diabetic ketoacidosis in a university setting. 1 Although the period of hospitalization was similar, the total number of laboratory tests and roentgenographic procedures and average number per patient per hospital day were notably increased in the specialist group, 17.02% and 13.13%, respectively. In a similar study comparing internists and family practitioners, we found that total laboratory use and length of stay per patient were increased in the internal medicine group by 67.77% and 10.65%, respectively. 2 In both studies, no difference in clinical outcome was noted. In addition, we compared laboratory test use in diabetic ketoacidosis at the same hospital in 1975 and 1980.

A partial test of a hospital behavioral model

The influence of hospital and community characteristics on the behavior of five dimensions of hospital output is examined in this article. These dimensions are the level of emergency stand-by capacity, total admissions, the diagnosis-mix of admissions and the hospital's ‘style of practice’ with regard to ancillary services and length of stay. A simultaneous equations model is estimated with data from a sample of 63 New England short-term general hospitals for 1970. The findings suggest that various types of short-term general hospitals have distinctive preferences for emergency capacity, volume, case mix and style of practice, and that style of practice may be more appropriately viewed as a rate of resource use per day. Specific findings of interest include the positive interdependence between protection against running out of emergency beds and length of stay, and between length of stay and ancillary service use. Hospitals that admit greater numbers of patients tend to treat more severely ill patients, and sicker patients tend to go to larger hospitals. Hospitals that provide more ancillary services tend to attract the more acutely ill patients. Relationships among other elements of the hospital's utility function represent trade-offs, i.e. substitution, in a constrained world. Among the exogenous factors, patient preferences and ability to pay have strong associations with the types of care provided by hospitals. Highly educated, high income communities, for example, tend to prefer risk averse, service intensive hospital output. Teaching hospitals are shown to prefer higher protection levels, service-intensive patterns of care, and higher admissions levels. Self-paying patients tend to be admitted for more discretionary types of diagnoses and to receive longer diagnosis-specific lengths of stay. A relatively greater supply of physician specialists in the market area is associated with increased use of ancillary services in the hospital. If replicated, these results have significant policy implications for reimbursing teaching hospitals; for defining accessibility of hospital care for the uninsured; for identifying the practice of ‘skimming’ by proprietary hospitals; and for specifying the role of community preferences in determining hospital performance, especially with respect to quality of care and level of emergency stand-by capacity.

The Use of Ancillary Services: A Role for Utilization Review?

Despite both the increasingly high cost of ancillary services such as laboratory tests, x-ray examinations and prescription drugs, and the authority provided to Professional Standards Review Organizations to review their use, ancillary services review remains underdeveloped. Several early programs have used claims review or profile analysis to assess the appropriate use of ancillary services and have claimed effectiveness in reducing medical care costs. Based on this experience, several principles for ancillary services review may be set forth, including problem identification, design of the audit system, determination of requirements for data and development of data sources. Evaluation of model ancillary service review programs is necessary to demonstrate their cost-benefit or cost-effectiveness and their validity.

The chronic pain syndrome: a physical and psychologic challenge.

The chronic pain syndrome differs from chronic pain. The syndrome is a psychologic stress state that can produce physical-type illness, often with musculoskeletal manifestations. It tends to strike the "worried well," by nature hysterical, depressed, hypochondriacal, and dependent. Standard medical, surgical, and psychologic treatments do not alleviate the pain. The chronic pain syndrome progresses only with enablement by the physician or indiscriminate use of ancillary services. An early complete history and physical examination are the basis from which the physician draws logical conclusions about the patient to prevent progression. The long-range solution lies in a dynamically structured, progressive physical and mental reactivation program implemented by a highly trained interdisciplinary team of professionals using a holistic approach.

Rising Hospital Costs and Service Intensity

The purpose of this study is to indicate how the change in a package of patient care services is related to changes in hospital costs. Based on the empirical results performed, one can argue that the inflation in hospital costs on both a per day and per treated case basis is in part explained by a set of patient care service intensity variables. Results of many studies of hospital cost behavior implicitly support the notion that changes in quality of services are related to changes in hospital costs. Although these studies did not explicitly consider variables for quality, the variables in these other studies embody factors for quality of hospital patient care services [6, 7, 9, 10, 12, 14,17, 20]. In this study, the purpose is to indicate explicitly how the change in a package of patient care services is related to changes in hospital costs. This study stems from observations made in several empirical studies funded by the Social Security Administration. The purpose of those studies was to examine the impact of a particular method for hospital cost containment called prospective reimbursement (PR), on the rise in costs of hospital care [ 1, 2, 5, 11, 15, 24]. One general conclusion of the studies was that the use of hospital services was related to actions taken by hospital decision makers, i.e., administrators, nurses and doctors, to contain the rise in hospital costs. Although the evidence varied, some observations justify the notion that costs and the use of certain quality enhancing patient care services are related. For example, Dowling et. all. [1 1] found that some indicators of ancillary service use were lower in the PR hospitals than in a set of control hospitals. Specifically, they found that the number of laboratory tests per case increased more slowly in PR hospitals than in control hospitals, while the number of X-ray films per case increased faster in the PR hospitals than in control Jeffrey E. Jarrett is a professor in the Department of Management Science at the University of Rhode Island. He has a Ph.D. from New York University and has published articles in several professional journals including Management Science, Decision Sciences, The Journal of Accounting Research, The Journal of Finance, The Accounting Review, The Journal of Business Finance and Accounting, and The Review of Economic and Business Research. Note: The author gratefully acknowledges the comments of Ernest Kurnow and several anonymous referees in earlier drafts of this manuscript. Thanks is also given to Sherry Allison-Cooke and Harvey Zimmerman for permitting the author to gather the appropriate data for the study.

Patterns of obstetrical care in hospitals.

This article examines the determinants of length of stay and ancillary service use for a single diagnostic category: normal delivery. Data for a systematic sample of 945 obstetrical admissions to 48 New England hospitals during 1969-70 are used to estimate a simultaneous equations model. The exogenous variables include socioeconomic and medical characteristics of the mother, medical condition of the newborn, type of labor and delivery, and hospital and physician characteristics. The important findings are threefold: First, evidence is found supportive of a simultaneous relationship between length of stay and ancillary services for normal deliveries. Second, the results show the importance of controlling for the performance of surgery, the presence of complications, the length of labor and the death of the baby in analyzing obstetrical utilization patterns. Third, holding maternal medical and socioeconomic factors constant, hospital size, teaching status, control and location, as well as physician mode of practice and relationship to the hospital, are important determinants of hospital use. It is concluded that the diagnostic-specific approach to utilization analysis is appropriate and useful. Only within such a narrowed focus can researchers disentangle the confounding effects of the attributes of the disease itself from the impact of hospital and physician characteristics on hospital use.