Utilization Review Committee Research Articles

Quality improvement project to reduce medicare 1-day write-offs due to inappropriate admission orders

BackgroundWe identified that Stanford Health Care had a significant number of patients who after discharge are found by the utilization review committee not to meet Center for Mediare and Medicaid Services (CMS) 2-midnight benchmark for inpatient status. Some of the charges incurred during the care of these patients are written-off and known as Medicare 1-day write-offs. This study which aims to evaluate the use of a Best Practice Alert (BPA) feature on the electronic medical record, EPIC, to ensure appropriate designation of a patient’s hospitalization status as either inpatient or outpatient in accordance with Center for Medicare and Medicaid services (CMS) 2 midnight length of stay benchmark thereby reducing the number of associated write-offs.MethodWe incorporated a best practice alert (BPA) into the Epic Electronic Medical Record (EMR) that would prompt the discharging provider and the case manager to review the patients’ inpatient designation prior to discharge and change the patient’s designation to observation when deemed appropriate. Patients who met the inclusion criteria (Patients must have Medicare fee-for-service insurance, inpatient length of stay (LOS) less than 2 midnights, inpatient designation as hospitalization status at time of discharge, was hospitalized to an acute level of care and belonged to one of 37 listed hospital services at the time of signing of the discharge order) were randomized to have the BPA either silent or active over a three-month period from July 18, 2019, to October 18, 2019.ResultA total of 88 patients were included in this study: 40 in the control arm and 48 in the intervention arm. In the intervention arm, 8 (8/48, 16.7%) had an inpatient status designation despite potentially meeting Medicare guidelines for an observation stay, comparing to 23 patients (23/40, 57.5%) patients in the control group (p = 0.001). The estimated number of write-offs in the control arm was 17 (73.9%, out of 23 inpatient patients) while in the intervention arm was 1 (12.5%, out of 8 inpatient patient) after accounting for patients who may have met inpatient criteria for other reasons based on case manager note review.ConclusionThis is the first time to our knowledge that a BPA has been used in this manner to reduce the number of Medicare 1-day write-offs.

Getting Out From Behind the Paraffin Curtain

In the course of a 30-year practice, I have had the opportunity to track the professional trajectories of more than a few pathologists, from entry level to midcareer and beyond. Patterns of success and failure emerge, so I am compelled to share some of my observations with trainees and newly minted practicing pathologists. It should go without saying that among the first obligations of any physician is mastery of the technical approach to the specialty. This is especially important in pathology, as from day one we are expected to deliver accurate and timely consultations with a very low error rate. I am pleased to say that the cognitive skills of newly trained pathologists have only risen steadily with time, and most all of them pass over that first very high bar with little apparent difficulty. The fractional distillation of careers—from failure, to mediocrity, to excellence—seems to be more a function of other personality traits and practice habits. I can summarize the most desirable of these as an eagerness to get out from behind the paraffin curtain, that zone of comfort at the microscope, where the well-trained pathologist can relax with a cup of coffee and a stack of slide folders. As viewed from behind the curtain, the ideal workday is one in which the biopsies are adequate, the histologic findings pathognomonic, and the diagnoses brief, definitive, and powerful. As we all know, those ideal workdays are infrequent. Biopsies are unrepresentative, histologic findings ambiguous, and important clinical information absent and difficult to obtain. From 23 years of practice in a general community hospital, I am all too familiar with the frustrations that arise in handling those very nontextbook cases. I discovered early on that relief would come only by venturing out from behind the paraffin curtain. I started by spending time with the radiology staff, reviewing images and discussing biopsy strategy prior to the procedure. I also encouraged the gastroenterology staff to call me to the endoscopy suite when they encountered any puzzling or otherwise unusual finding. Additionally, I began to spend time in surgery, reviewing the operative schedule the afternoon before, noting cases that were likely to attract consultation, and appearing in the operating room as the procedure was getting underway. These ministrations outside the laboratory, although time consuming, were eventually rewarded not only with specimens of greater technical quality but with a boost in my own self-confidence as a diagnostician. An unexpected side effect of these adventures was an introduction to hospital politics.

Hospital Case Management and the Utilization Review Committee

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. Acute care hospitals. 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.

363: Obese Dosing Adjustments for Selected Antimicrobials in the Emergency Department

The Centers for Disease Control and Prevention have reported a dramatic increase in obesity over the past 20 years in the United States, making obesity a public health crisis. Emergency physicians should be aware of pharmacokinetic and pharmacodynamic changes in the obese population. We evaluated whether our institution's emergency physicians are adhering to dose adjustment for selected antibiotics based on guidelines from our antibiotic utilization review (AUR) committee.

Yes, Things Will Change in Your Facility

Yes, Things Will Change in Your Facility

Management of Warfarin Associated Intracranial Hemorrhage with a 3-Factor Prothrombin Complex Concentrate and Low Dose Recombinant Factor VIIa.

Background: Intracranial hemorrhage (ICH) is a serious complication of warfarin therapy. Plasma infusion is the current standard of care in the US, even though most guidelines recommend prothrombin complex concentrate (PCC) as the preferred therapy; PCC has several advantages over plasma including no ABO blood type requirement, no lengthy thawing and infusion process, and a very small volume of virally inactivated pure vitamin K-dependent factors (VKDF) content that causes neither volume overload nor TRALI. Ideal PCC should contain adequate amounts of all VKDF (4-factor). As our group reported at the 2006 ASH meeting, PCC currently available in the USA have a very low FVII content (hence called a 3-factor PCC), often resulting in an incomplete correction of supratherapeutic INR. PCC is, therefore, often supplemented with 1–2 units of plasma to provide FVII; however, many elderly patients on warfarin do not tolerate an additional fluid volume and there is an urgency to correct coagulopathy in ICH. Recombinant FVIIa (rFVIIa) has been used to reverse warfarin effect with variable success. An experimental model has shown that rFVIIa corrects PT/INR in vitro but fails to correct bleeding because it does not address FII and X deficiencies critical for thrombin generation in vivo when compared with PCC. Therefore, we developed a trauma coumadin protocol (TCP) for urgent warfarin reversal for ICH, which includes both PCC and a low dose rFVIIa.Methods: TCP was approved by the Blood Utilization Review Committee of the Parkland Memorial Hospital and consists of administration of 4000 IU PCC (Profilnine, Grifols) and 1.2 mg rFVIIa; 5 mg intravenous Vit K1 is also administered daily for 3 days. PCC contains FII no more than 150 units, FX no more than100 units, and FVII no more than 35 units for each 100 units of FIX. Pre- and post-TCP VKDF were measured when possible (Table 2). We compared 19 patients treated with TCP with a 12 patient-non-TCP control group (warfarin-ICH) treated either with plasma alone (n=3) or plasma plus PCC (n=9). We will also compare (software delay) the 2 groups for extension of hematoma volume; the radiologist will be blinded to the therapy.Results: The TCP group included 12 females and 7 males aged 46–87 years (median 64). The control group included 4 females and 8 males aged 53–89 years (median 73). TCP patients had significantly faster as well as complete correction of PT/INR as compared to the controls. (Table-1). Post-TCP CT scans showed stable hematomas. 1/19 TCP patients with pituitary adenoma had pre-TCP INR of 7.2 and post-TCP INR of 0.9. He developed thrombotic stroke and acute myocardial infarction 2 days later; he was discharged home. The patient received 2.4 mg of rFVIIa because initially the dose of rVIIa was stratified based on INR (1.2 mg for INR 5.0 or less and 2.4 mg for INR greater than 5.0). . Examination of post-treatment FVII levels (Table-2) led us to modify TCP rFVIIa dose to a 1.2 mg, irrespective of INR.Conclusion: TCP rapidly and effectively corrects warfarin-associated coagulopathy in patients with ICH. Because thrombotic complications remain a concern, 4-factor PCC should further be evaluated.Table 1.Test resultsTime relative to TCP treatmentTCP group n=19Control group n=12p valueINR Mean ± SD (range)Pre3.1±2.0 (1.4–5.1)3.2 ±1.6 (1.4–7.2)0.991Post1.1±0.3 (0.9–2.0)1.4 ±0.3 (0.9–2.0)0.003PT Mean ± SD (range)Pre28.1±17.3 (13.5–65.1)28.9±14.0 (13.7–62.6)0.887Post10.7±2.2 (9.3–18.1)13.8±2.8 (9.3–18.3)0.002PTT Mean ± SD (range)Pre36.0±10.3 (21.8–59.8)38.2 ±11.5 (25.4–60.6)0.591Post24.7±4.2 (19.5–32.2)27.8±4.5 (22.8–30.9)0.058Time from TCP to INR correction (min)Mean ± SD (range)145.4±107 (22–329)267±76 (83–697)0.023Median111240Table 2.Test resultsINRPTPTTFIIFVIIFIXFXPretreatment Mean ± SD (range)3.3±2.0 (1.5–7.4)29.6±17.3 (14.4.–65.1)35.7±9.9 (30.1–54.7)54±41 (6–117)23 ±12 (6–37)57 ±28 (17–96)44 ±30 (5–74)Posttreatment Mean ± SD (range)1.1±0.4 (0.9–2.0)11.0±3.0 (9.4–18.1)25.9±4.1 (19.5–32.2)148±84 (27–323)394±141 (114–600)97±22 (58–130)144±54 (89–268)

Efficacy of Prothrombin Complex Concentrate (PCC) for Reversal of Warfarin Effect.

In the United States supratherapeutic INRs are typically reversed with fresh frozen plasma (FFP). This requires transfusion of large volumes (10–15 ml/kg) with therapeutic delay, volume overload, risk for TRALI (transfusion related acute lung injury) and multiple donor exposures. Our Blood Utilization Review Committee recommends PCC as the preferred product for warfarin reversal. Profilnine (Alpha Therapeutic Corp, Los Angeles, CA) is PCC containing vitamin-K dependent clotting factors and dosed by FIX content. FII, VII and X content is no more than 150%, 35% and 100% of the FIX amount, respectively. The manufacturer's suggested dose for warfarin reversal is 15–50 U/kg. The dose of PCC and need for vitamin K or FFP is determined by the clinician after consultation with the transfusion service. Sixty-five patients received PCC; 25 for reduction of INR prior to surgery or other interventions and 40 for treatment of a supratherapeutic INR (>5.0) with bleeding or risk of bleeding. Twenty-three patients with supratherapeutic INRs received low dose PCC (mean 25 U/kg) and 17 received high dose (mean 50 U/kg). The average admission INR was 9.0 (5.2–15.0) for the low-dose group and 8.6 (5.3–15) for the high-dose group. Repeat INR measurements occurred after PCC and again if FFP was transfused. Twenty patients had samples frozen for analysis of FII, VII, IX and X with a mean time between PCC infusion and sample draw of 2 hours (0.5–8.1). Ten of these were stable at the time of PCC infusion and were used to calculate relative factor recovery. The INR corrected (decreased to ≤3) in 55%(6/11) of cases following treatment with low-dose PCC, while high-dose PCC corrected the INR in 43%(3/7). Combination of PCC and FFP (mean 2 units, ~5–7 mL/kg) corrected the INR in 89% (16/18) and 87%(13/15) of cases for low and high-dose PCC, respectively. PCC dose, with or without FFP, had no effect on the likelihood of INR correction (Chi-square, p> 0.05). The addition of low dose FFP, however, significantly increased the response rate (Chi-square, p<0.05) for both doses. The average factor increment is summarized in Table 1. Differences in factor levels between the PCC and PCC plus FFP groups were not significant(ANOVA, p>0.05). Based on PCC dose the median recovery of factor IX was 100% with a median recovery for FII, VII and X of 168%, 32%, and 100% of the factor IX increment. When FFP was added to the treatment regimen the recovery of factor IX was 106% of the PCC dose. FII, VII, and X were 182%, 46%, and 119% of the FIX increment. Only FVII recovery was significantly higher in the PCC plus FFP group (Mann-Whitney, p< 0.05). In conclusion, treatment with Profilnine increases factor levels compatible with the manufacturer's insert, but PCC plus FFP causes a larger FVII increment. Treatment with low or high dose PCC results in similar rates of INR correction. However, addition of FFP increases the rate of INR correction for both doses. Profilnine alone is, therefore, unable to reliably correct a supratherapeutic INR, and supplementation with small amounts of FFP is necessary to provide additional FVII. A PCC product with a higher content of FVII is a better therapeutic option but is not readily available in the United States.Factor increments following PCC infusionINRF II(%)F VII(%)F IX(%)F X(%)PCC onlyPre8.3±4.511±107±710±106±3Post2.6±1.453±2114±1028±1931±12PCC plus FFPPre12.2±5.05±11±112±1912±19Post1.9±0.876±2820±1245±2253±19mean±SD

The ethics of clinical pathways and cost control.

You are the Chief of Vascular Surgery in a large community hospital that has been experiencing financial difficulties. Your division has been cited by the Utilization Review Committee for excessive lengths of stay in the ICU and hospital wards. After weeks of deliberations, with minimal input from surgeons, you are directed by the hospital Executive Committee to implement a fast-track clinical pathway for all patients undergoing major vascular procedures. Your staff surgeons believe that the data suggesting excessive lengths of stay are flawed and that the new directive may significantly increase postoperative morbidity and mortality. Your most responsible ethical action is which of the following?

A comparison of hospital length of stay versus the early transfer to a skilled nursing facility: the effect on direct costs of total joint arthroplasty

The direct costs of total joint arthroplasty are multifactorial. Third party payers, managed care organizations and hospital utilization review committees continue to monitor each surgeon's cost profile in total joint arthroplasty. The length of stay in hospital and transfer to a skilled nursing facility (transitional care unit or nursing home) are considered to be major determinants in the direct costs of total joint arthroplasty. The direct costs hospitalization, transitional care unit and nursing home stay were analyzed for 971 primary total hip and knee arthroplasties performed in three hospitals in St. Paul, Minnesota between September 1992 and December 1993. Those patients who were discharged directly home with or without home healthcare had lower direct costs than those transfered to a transitional care unit or nursing home. Despite the emphasis on decreased length of stay for achieving cost containment, keeping the patient hospitalized for up to 7 days can result in lower total direct costs for total joint replacement compared to early transfer to a transitional care unit or nursing home.

Utilization review for Medicaid diagnosis-related group systems: practice, innovation, and lessons of experience.

Utilization review practices, innovations and trends for the 21 states using diagnosis-related groups for Medicaid during 1992 are described. According to this descriptive survey, Medicaid inpatient utilization review programs vary widely in authority, approach and focus, reflecting state payment system incentives, health and hospital system characteristics, and provider practice norms. More than half of the states with Medicaid diagnosis-related group systems contract with a Medicare Peer Review Organization. State programs are developing complementary clinical and data analytic approaches, advised by multidisciplinary utilization review committees, and are moving from random review to strategies that focus on specific types of admissions/procedures, and shift as provider practices and utilization patterns change. Utilization review strategies also support payment incentives and system features, e.g., by targeting outliers, readmissions and transfers, and short stays. Overall, programs are becoming more flexible, targeted, and interactive. Trends and suggestions for refining utilization review programs for diagnosis-related group systems are presented.

Prescribing Practices of Outpatient Child Psychiatrists

This study was designed to assess outpatient child psychiatrists' prescribing practices. Of 1,422 outpatients in two public, university affiliated settings in New York and Ohio, the charts of 146 medicated and 126 nonmedicated randomly selected patients were reviewed for demographic variables, DSM-III-R diagnoses, medications prescribed, and charted prescription rationales. Fifteen percent of the 800 outpatients seen in a 1-month period in New York, and 19% of the 626 outpatients seen in a 1-year period in Ohio were prescribed medication. Patients medicated by clinic psychiatrists were significantly more likely than nonmedicated patients to be psychotic and to have been hospitalized previously, and significantly less likely to have adjustment disorder. Using standards employed by drug utilization review committees, medications were prescribed appropriately in approximately 90% of cases. Of concern, 65% of patients given antipsychotics in New York and 67% in Ohio were not psychotic; the primary target symptom in such cases was aggression. Prescribing practices appeared to be appropriate, although the use of antipsychotic medications in nonpsychotic children is a concern for the field of child psychiatry. The strong similarity of practices in two independent and geographically remote sites suggests the findings are generalizable to providers in other public, university affiliated settings.

Institutional responses to Medicare's prospective payment system

The introduction of Medicare's prospective payment system (PPS) meant an important change in the environment of US hospitals. The new payment system was expected to improve clinical and non-clinical efficiency in hospitals. A case study in a non-profit Pennsylvania hospital was performed to analyse the impact of PPS on hospital services. The hospital responded to PPS by a twofold strategy. First, attempts were made to achieve effective cost containment by improving the efficiency of intermediate and final outputs. Here special attention is paid to the activities of the DRG coordinator and the Utilization Review Committee and to the activities of nurses in their role as case manager. The second strategy was directed at revenue enhancement, initially mainly by shifting more costs to non-Medicare patients and later by trying to strengthen the position of the hospital in the local health care market. This second strategy was considered more important than the strategy of cost containment. With respect to organizational structure and policy-making, the following changes can be observed: a growing importance of strategic management; more integrated hospital-physician relationships; and the development of an adequate medical information system and a medical records department.

PSRO—Quality control? Or gimmickry?

The implementation of quality control programs of health care service requires a technology no less complex than that of the quality control program itself. Previous efforts to implement programs where health care practitioners are truly accountable have foundered on: 1. The lack of enthusiasm of major third party payers, 2. The functional inadequacies of Medicare utilization review committees, and 3. The conflict of interests of medical societies. For the Professional Standards Review Organizations (PSRO) to be effective rather than ceremonial, evaluation that is arm's length between evaluator and practitioner is indispensable. The PSRO is the last chance for organized medicine to demonstrate that it can and will control those practitioners who habitually do violence to its ethical and professional norms. The paper lists other options should the presently structured PSRO program fail.

Statewide helicopter utilization review: The Massachusetts experience

Air medical services began in Massachusetts in 1982, and Utilization Review (UR) of both programs in the state began in 1985. The UR program consists of external review of all flights according to screening criteria established by an independent Helicopter Utilization Review Committee (HURC). Between 1982 and 1989, over 2,500 flights were reviewed, with under 2% deemed inappropriate by the committee. Results of this process have helped to improve referrals from specific prehospital and hospital care providers, identified specific patient groups of interest, such as those transported for transplants or because of hospital bed shortages in specific regions, and assisted with improved third party reimbursement. Utilization review has not yet assisted with identification of unmet need or inappropriate resource utilization by ground ambulances, and has not compared the outcome of equal levels of care provided by different transport modes. We conclude that a coordinated utilization review process can be of benefit to both patients and air medical services.

Unit-Based Clinical and Organizational Indicators for Residential Treatment

A psychiatric residential treatment center has developed a system for monitoring and evaluating the quality of care provided. Administrators of the nine residential treatment units of the Devereux Foundation's Edward L. French Center use a standard form to report on a number of uniform clinical and organizational indicators. The data are evaluated monthly by the utilization review committee, quarterly by the quality assurance committee, and semiannually and annually by other administrators, committees, and the foundation's board of trustees. This process has been an effective mechanism for identifying trends and patterns in client care, for improving client care, and for providing clues to relationships among organizational problems.

CONSENT: IN RESEARCH AND IN DAILY PRACTICE

It is arguably the case that informed consent requirements have affected human research more deeply than they have the practice of clinical medicine, and that this is so at least in part because informed consent in research has been mandated and monitored by federal controls and regulations that link funding for research to consent procedures. However, it is doubtful that. . . adding review of consent forms to the tasks of utilization review committees would have the same level of impact on clinical medicine as the institutional review board system has had on human research. Institutional review boards are a system of prior, rather than after-the-fact, review they are concerned solely with questions of research ethics; and they are in a position to address questions of voluntariness and competency in a way utilization committees could not.

The International Congress on Peer Review in Biomedical Publication

"Peer review" has a variety of meanings for physicians. All physicians are accustomed to surveillance of their use of hospital beds or of the records they keep about the patients in those beds by utilization review and quality assurance committees made up of their peers. Physicians face yet more peer review when they double as investigators, put their proposals before institutional review boards, and have their grant applications assessed by expert panels of their peers. Finally, the product of all this—the manuscript that embodies their scientific brainchild and carries their hopes of fame and promotion—is subjected by journal editors to yet another round of peer review. Understandably, it is this last version that tends to interest journal editors the most. However, the workings of the editorial peer review system are of vital concern to every scientist and ultimately to all physicians and patients because all the important advances in science

Use of Anticholinergics in the Nursing Home: An Empirical Study and Review

The Medicare Utilization Review Committee conducted a survey to determine the use of drugs with anticholinergic effects in confused elderly nursing home patients. Twenty-nine patients (34.5 percent) were receiving anticholinergic drugs, predominantly from the antidepressant and antipsychotic class. Thioridazine (Mellaril) was the most frequently used antipsychotic. No patients received higher than the equivalent recommended daily dose of atropine when calculated in terms of relative anticholinergic potency. No statistically significant correlation could be found between the presence of confusion and the amount of anticholinergics administered. Confusion and cognitive deterioration frequently are encountered when caring for aged patients. Clinical experience and recent studies suggest that anticholinergics may increase the risk of or exacerbate existing confusion, and this possible effect of anticholinergic activity should be considered when prescribing for elderly patients.

An automated PSRO-utilization review system.

A set of computer programs collects, processes, and reports Professional Standards Review Organization (PSRO) and utilization data for all patients at the Miami Heart Institute. They help reduce the time spent by physicians in PSRO and utilization review activities and ease the clerical work load required to comply with rules and guidelines. Daily printed reports provide attending physicians with their patient census and inform them of the next scheduled PSRO review dates for each of their patients. Reports are produced also for the Utilization Review Committee and the Institute's PSRO office. This set of programs is part of a comprehensive automated hospital information system and has been designed to respond rapidly to the frequent changes in regulations and policies dictated by the administering agency. The PSRO subsystem had been in uninterrupted operation for over 6 years and has mitigated escalating clerical and, therefore, health care costs. Physicians' acceptance of this subsystem had been adequate; however, developmental and maintenance costs are high in comparison with other applications within the hospital information system. This article describes the methodology used in complying with PSRO requirements. It does not attempt to evaluate the impact of PSRO on quality of care or length of hospital stay.

Diagnostic services utilization review at a university medical center

The rational provision of diagnostic services is important in maintaining health care quality and controlling costs. Establishing a successful diagnostic services utilization review committee requires substantial commitment from the hospital and the medical staff.