Utilization Review Committee Research Articles

Utilization review committee as a peer review mechanism.

The appropriate utilization and the quality of care in long-term care facilities should be documented and monitored. This is best accomplished at the local level by physicians and other professionals serving on Utilization Review Committees. Paper compliance to regulation of state or federal agencies is a poor substitute for active involvement of the professionals at the local level.

Jefferson Medical College Student Model Utilization Review Committee.

A Student Model Utilization Review Committee Project is in progress at Jefferson Medical College. Students participate in the program for 90 minutes during the six weeks of their clerkship in family medicine at the university hospital. Information collected from participants and controls before and after the program indicates that the experimental group has greater knowledge and more positive attitudes about utilization review and cost control in the health care field than do the controls. Students express positive feelings about the program. More importantly, one year later, as seniors, those in the experimental group demonstrated clinical behavior which was more consistent with the objectives of the program than other students. These results have led the Department of Family Medicine to incorporate the utilization review program into its formal curriculum beginning in the 1979-1980 academic year.

Comparative evaluation of the effect of a high yield criteria list upon skull radiography.

Based on results of studies using high yield criteria to determine the need for skull radiography, the Utilization Review Committee of the University Hospital (UH), University of Washington, Seattle implemented a policy encouraging use of the criteria in ordering skull radiology. The Bureau of Radiologic Health of the FDA supported a project comparing skull radiology use patterns at UH, with the high yield criteria policy, and Harborview Medical Center (HMC), without a policy. Results showed an increase of around 60% at HMC since the 1972--73 academic year. At UH, there was a decrease of 40% since the 1972--73 academic year. At HMC a medical record review showed only 51 positive reports that significantly contributed to patient care, about the same rate observed in 1967. At the UH, only nine positive reports significantly contributed to patient care, with 62% compliance with the high yield criteria. A current demonstration project under the auspices of the Washington State Professional Standards Review Organization and Bureau of Radiologic Health involves implementing the high yield criteria list at both HMC and UH. After three months, out of 6,003 patient visits, skull radiography was deemed necessary in 518 cases. Of this total 181 had high yield criteria checked. There were 37 positive reports out of these and 23 examinations that made a documented significant contribution to patient care. In the group without high yield criteria, 434 cases, there were 22 positive reports but no significant contribution to patient care documented after four weeks.

Are Medical Education Dollars Buying What They Should?

WHETHER or not it sticks in the craw, by federal mandate, health planning does exist, as do the specter of comprehensive national health insurance plans, and the Federal Trade Commission with its alledged assaults on professionalism. There are watch birds set up to control utilization and quality through Professional Standard Review Organizations, audits, and utilization review committees; the $2.7 billion authorized for health professions education by the new health manpower law comes with many strings attached. The public, at least in its federal form, has increasingly been involved in health care and medical education. I was asked to speak for the public interest. I cannot legitimately speak for all my fellow citizens. We even have difficulty according our highest popularly elected officials the power to speak for us. So, with that disclaimer, I will speak about medical education dollars and the public interest. DOLLARS, DISTRIBUTION, DISAFFECTION, AND QUALITY The key

A computer package to facilitate compliance with utilization review requirements.

The Cumberland County CMHC in Fayetteville, North Carolina, developed a series of computer programs to produce the information that is required by area regional utilization review committees. There is a total of eight programs. The first establishes a master file and prints out all the information that has been gathered on all the clients. The other seven programs retrieve various portions of the data stored in the master file. The system does not require elaborate in-house computer equipment. It is easy to operate and benefits clients by enabling clinical staff to spend less time on documentation and more time on direct treatment.

Auditing care with a problem-oriented record system

The trend toward formal evaluation of medical care prompted the examination of the quality and economy of care in the emergency department of Beth Israel Medical Center. Two sources were used to obtain the information for the evaluation. The first was the Emergency Department Utilization Review Committee which meets every other week to review emergency department charts. The second was a study to determine the speed of audit and time to fatigue in auditing emergency department charts. The results showed that auditors could review problem-oriented charts in less time and in greater numbers with less fatigue than traditional charts.

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.

A chart-review checklist for utilization review in a community mental health center.

As an aid to utilization review in a community mental health center, a checklist has been developed that nonclinical personnel can use to help assess the adequacy of patient care, as reflected in the medical chart. The review is carried out on three levels. All charts are reviewed in the records room to make sure that all necessary forms are complete. On charts selected for more intensive review, the nonclinician reviewer responds to a series of yes-no questions about the quality of care or adequacy of information. If short-comings are found, the chart is then reviewed by a senior clinician to determine whether the care is in fact inadequate. The utilization review committee discusses instances of inadequate care with the clinician involved in the case, and also reviews with the administration any policy issues raised by the problems uncovered.

The Hospital Admission and Surveillance Program in Illinois

Methods for establishing peer review and medical quality control are much discussed but rarely implemented programs. To a minor degree, partial programs have been established as experimental models. To date, there has not been a statewide program which encompasses peer review, medical review, monitoring and training of institutional utilization review committees, and an information system to ascertain the quality of care obtained by state medical assistance patients. The Hospital Admission and Surveillance Program represents a method for fulfilling the requirements of two health interests. The medical profession retains its role in providing professional evaluation and medical review while the state monitors and more efficiently purchases care for the indigent.

Utilization review in a large mental hospital.

FTER the Social Security Amendments of 1965 were passed, all hospitals in the United States were under considerable pressure to prepare themselves for medicare by the target date of July 1, 1966. To participate in tile medicare program, an institution must meet certain requirements, one of which is to develop and implement a utilization review systern, to be carried out by a special committee. The task of tile utilization review committee is to review the duration of stay and the professional services furnished for a sample of admissions and to review each case of “continuous extended duration.” Before they do so, the committee must define various terms, such as “continuous extended duration,” in some practical way. General hospitals had been using utilization review before the advent of medicare. However, it had not previously been part of the formal structure of psychiatric hospitals. And although utilization check lists for various physical diseases existed as part of the medical utilization studies, there was no comparable check list for psychiatric disorders that could be used by large public mental hospitals. The problems of making such a list are considerable, compared with devising a check list of relevant factors in physical diseases. For example, there are standards for length of stay and specific treatments for many medical conditions, such as appendicitis or gall bladder disease, but not for psychiatric illnesses. Specific medical disorders call for specific diagnostic tests, such as the electrocardiogram for cardiac conditions, whereas a more general series of clinical examinations is the

Utilization Review Committees: Statement of the Problem

As recently as 30 years ago, there was little concern with whether hospitals were being used effectively. The overall admission rate was 59 per 1,000 persons. But great changes in the system of medical care, gradually evolving medical science, changes in public attitudes, development of prepayment mechanisms, and other factors have combined to change this. Last year the admission rate to short-term general hospitals was 135.8 per 1,000. Although the vast hospital construction program that followed World War II had laced the nation with a network of hospitals and expanded the bed supply significantly, the increased demand for hospital care more than kept pace. In 1953, the occupancy rate for nonfederal, short-term general hospitals was 72%. By 1964, it had risen more than four percentage points to 76.3%, even though 500 hospitals and almost 175,000 beds had been added in the interim. To a degree, averages are myths. The reported