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Abstract Background We 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. Method We 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. Result A 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. Conclusion This 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.

Background: We 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. Method: We 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. Result: A 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. Conclusion: This 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. [ABSTRACT FROM AUTHOR]

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Background and aims: This is a narrative report on the development of specifications and of the stepwise implementation of a computerized physician order entry system (CPOE) in the University Hospitals Leuven, based on order sets integrated in care pathways. Integration of the CPOE into the electronic health record optimally supports those care pathways. Materials and methods: We investigated adherence to consensus-based use of laboratory tests. We analysed data post- versus pre-implementation test requests for departments selected to cover various patient populations, using the Mann-Whitney U test corrected for the False Discovery Rate. Results: We investigated the effect on the number of tests post- versus pre-implementation. In the emergency and inpatient wards, the CPOE implementation resulted in decreases in requests for uric acid, total protein, direct bilirubin, reticulocyte count, and increases in requests for albumin, glucose and calcium. In the outpatient clinics, where the medical specialties already used non-computerized consensus-based test requesting strategies, effects on the number of requested tests were marginal. In all settings, operational improvements could be inferred: the centrally managed CPOE system resulted in fast and well-controlled management of test strategies, digital traceability of the laboratory test requesting process, automatic archiving of requests, assurance of availability of obligatory information. Conclusions: Overall, test requesting strategies improved towards more consensus-based and operational benefits resulted in time gains and improved efficiency of time spend.

Purpose The current study aimed to identify the overall characteristics of cancer-related emergency department (ED) visits by adult in Korea, including analyses of factors associated with ED stay time and outcomes nationwide. Materials and Methods We collected data on cancer-related ED visits from the National Emergency Department Information System (NEDIS) database between 2017 and 2019. Results ED visits by cancer patients comprised 5.5% (667,935 visits) of total ED visits from 2017 to 2019, which was slightly higher than in other counties. Patients with cancer who visited the ED were over 50 years old, the majority being males, and patients with cancer visited EDs in certified tertiary hospitals more frequently than patients without cancer. In multivariate analyses, the adjusted odds ratio for a length of stay more than 8 hours in the ED of certified tertiary hospitals was 126.34 (95% confidence interval, 1.422 to 1.460) when compared to hospitals. Nevertheless, the longer the patients stayed in the ED, the more likely they were to be admitted. Conclusion The longer ED stay and higher proportion of cancer patient hospitalizations suggest that cancer patients visit ED to be admitted as well as to receive acute care. The frequency of ED visits and admission may be adjusted to some extent depending on outpatient education, such as self-management of symptoms and situations. Improving cancer care in local communities should be met though provisions such as linking treatment between hospitals or supplying appropriate medical personnel, even for the efficient use of ED resources in hospitals. [ABSTRACT FROM AUTHOR]

• In the seven years before the COVID-19 pandemic, the use of both enhanced and unenhanced CT has been consistently increasing. • Temporal trends in enhanced and unenhanced computed tomography use are significantly associated. • In the first year of the COVID-19 pandemic, there was a marked decrease in both enhanced and unenhanced CT use. • If pre-pandemic CT use trends continue, a further increase in contrast media supply will be necessary. [ABSTRACT FROM AUTHOR]

Introduction: Management of patients with suspected heparin‐induced thrombocytopenia (HIT) can lead to significant costs. Reported cost‐saving initiatives have focused on minimizing inappropriate testing in low‐risk patients and optimizing alternative anticoagulant selection. We sought to further investigate how utilizing various HIT laboratory testing models would impact total cost of testing and alternative anticoagulant use. Methods: Utilizing a retrospective cohort of adult patients tested for HIT over three years within our institution, we evaluated how utilization of four distinct laboratory models impacted total number of HIT test combinations completed, time to HIT testing finalization, percentage of patients discharged from the hospital prior to HIT testing finalization, total alternative anticoagulant days, and total anticipated major bleed events. Additionally, we calculated cost of laboratory testing and alternative anticoagulant associated with each model. Results: A total of 482 patients were included in our cohort. A laboratory testing model that utilized an in‐house platelet factor 4 (PF4)‐heparin enzyme‐linked immunosorbent assay (ELISA) completed three days weekly, and reflex serotonin release assay (SRA) with a five‐day turnaround resulted in the shortest mean time to HIT testing finalization, lowest percentage of patients discharged prior to HIT testing finalization, and lowest total alternative anticoagulant days. Conclusions: Institutions should evaluate current HIT laboratory testing practices and assess for opportunities for optimization. Testing models utilizing a PF4‐heparin antibody ELISA with a reflex SRA for positive results may improve testing metrics and lead to lower utilization of alternative anticoagulants. [ABSTRACT FROM AUTHOR]

Paraneoplastic syndromes are rare conditions associated with characteristic autoantibodies produced by malignancy, although similar autoantibodies and clinical presentations may occur in the absence of any neoplasm. Testing for paraneoplastic syndromes often involves panels of autoantibody assays. While autoantibody testing may reveal or confirm actionable clinical diagnoses, inappropriate utilization of testing may be low yield and further lead to false positives that may confuse the clinical picture. There is thus opportunity to improve patient care by analyzing patterns of paraneoplastic autoantibody test utilization. The data in this article provides results from detailed retrospective review of patients tested by 7 autoantibody tests or test panels offered by two large reference laboratories in the United States. The data include 1,446 tests performed on 1,338 unique patients at an academic medical center. For all results, detailed chart review revealed main category of presenting symptoms, patient location at time of testing (either inpatient or outpatient), sex, age, whether cancer was present at the time of testing or later detected, and the specific results of the testing. The data are summarized by category of testing and specific autoantibodies.

• The utilization patterns of medical services vary among patients with insomnia. • This retrospective cohort study analyzed National Health Insurance Service data. • Only 46.21 % of newly diagnosed insomnia patients received more than two treatments. • 67.35 % opted for conventional medicine, while 26.85 % chose Korean medicine. • Patients with insomnia preferred monotherapy to combined treatment in South Korea. Patients with insomnia can use Korean medicine (KM) alongside conventional medicine (CM) as treatment options within the Korean healthcare system, but the treatment patterns for insomnia remain unclear. This study evaluated the incidence of newly diagnosed insomnia and medical service utilization, including untreated, CM, KM, and concurrent use of CM and KM, and the determinants of treatment after the insomnia diagnosis. This retrospective cohort study analyzed adult Korean patients newly diagnosed with insomnia between 2016 and 2018 using National Health Insurance Service data. The cohort who met the eligibility criteria for insomnia was followed up until 2019 to identify their medical service utilization and the determinants. The medical service utilization was defined based on outpatient visits or hospitalization records with insomnia as the primary diagnosis. Descriptive statistics and logistic regression analysis were used to identify the medical service utilization and its determinants. Among the 336,578 patients newly diagnosed with insomnia in 2016–2018, only 155,538 (46.21 %) received more than two insomnia treatments during the follow-up period. Of these, 104,751 (67.35 %), 41,762 (26.85 %), and 9,025 (5.80 %) patients received CM monotherapy, KM alone, and both CM and KM, respectively. The statistically significant factors for receiving insomnia treatment after diagnosis were female, age ≥30 years, Seoul capital area residents, lowest income quintile, National Health Insurance Service (NHIS) enrollment types excluding the employee type, and longer elapsed time after diagnosis. The factors for receiving KM alone rather than CM alone were female, aged 40–79 years, residents of the Seoul capital area and metropolitan city, higher income, employee type among the NHIS enrollment types, and a more recent diagnosis. The common factor for concurrent use rather than CM alone was aged 40–79 years, and concurrent use rather than KM alone was being male. More than half of the patients with insomnia received treatment only once. The utilization of CM or KM alone was higher than that of their combined use. Healthcare professionals can utilize these findings to manage patients with insomnia effectively. [ABSTRACT FROM AUTHOR]

Background. The family physician (FP) is vital for the continuity of care (CoC) and is also a reliable guide in choosing the preferred treatment pathways, which lead to a reduction in the utilization of unnecessary services. Objectives. To investigate the utilization of outpatient services in the Fars province as a pilot center for the urban family physician program (UFPP) and East Azerbaijan. East Azerbaijan is a province which has been selected for comparison (control) through clustering. Material and methods. This population-based, comparative and cross-sectional study was conducted in Iran. Retrospective data on specialists/subspecialists visits (SSV), prescribed medicine (PM), laboratory services (LS) and medical imaging services (MIS) was obtained from administrative claims data of the Iranian Health Insurance Organization (IHIO) for a random sample of 4,800 people between September 2017 and September 2018. Results. Overall, 50.2% of the participants were female. In the Fars province, the mean SSV, PM, LS and MIS utilization during the study period was 1.21, 3.05, 0.49, and 0.29, respectively. These amounts were 1.14, 1.71, 0.36 and 0.21, respectively, in East Azerbaijan. Multivariate analysis showed significant differences in the utilization of SSV, PM, LS and MIS between provinces (p < 0.05). The largest difference was observed in the utilization of PM by a mean difference of 1.33 (1.17–1.50, p < 0.001). Females were associated with more PM utilization (p = 0.003), and older people utilized more outpatient services (p < 0.05). Conclusions. Unexpectedly, after five years of the implementation of UFPP, utilization of services was higher in Fras than East Azerbaijan. Improved access by removing barriers, especially for women and the poor, as well as program execution problems could be the reason for these results. Further research is urgently needed to solve this mystery. [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients.Design: Single-center cluster randomized crossover trial.Setting: Two medical ICUs at Barnes Jewish Hospital.Patients: Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality.Interventions: The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission.Measurements and Main Results: Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) (p > 0.05).Conclusions: Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients. [ABSTRACT FROM AUTHOR]

Background and Aim: In attention to pressing need to cost containment and service efficiency, laboratory services serve as a central locus for controlling health care expenditure. This study intents to investigate proportion of laboratory utilization in Iran to pave the way for future interventions. Materials and Methods: A cross-sectional study was conducted to investigate the proportion for laboratory utilization through the retrospective analysis of 384 medical records at the tertiary care Kashan University Hospital Shahid Beheshti. To pave the way for future intervention, over utilization tests were classified into two categories, inappropriate and resulted in laboratory errors. Results: Nine thousand five hundred forty one laboratory tests were ordered, 2522 (26.40%) of the tests were inappropriate and 143 (1.5%) of the over utilization tests have occurred due to laboratory testing cycle errors. According to reviewers’ judegment relevancy to medical intervention was considered as the most accepted appropriateness criteria 5012 (52.53%) for laboratory tests Conclusion: Since, the laboratory tests over utilization is multifactorial, forming a multidisciplinary team including physicians, nurses, laboratory staff, medical education experts, health care management and health information technology staffs in terms of Utilization Committee to develop more targeted strategy based on root cause analysis of over utilization behavior seems necessary.

As emergency department (ED) crowding continues to worsen, many visits are at academic referral hospitals. As a result, engaging specialty services will be essential to decompressing the ED. To do this, it will be important to understand which specialties to focus interventions on for the greatest impact. To characterize the ED utilization of non-surgical adult patients with an ambulatory specialist who were seen and discharged from the ED. Retrospective cohort study of all consecutive patients currently under the care from a specialist presenting to an urban, university affiliated hospital between 01 January 2015 and 31 December 2016. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. Only patients who were discharged directly from the ED were included in the analysis. There were 29,853 ED visits by patients currently under the care of a specialist during the study period. 17.76% of these visits were related to the medical specialty of the specialist. Of these visits, 41.73% occurred during office hours, and 24.81% occurred during weekends. The specialties with the largest proportion of ED visits related to their specialty was cardiology, gastroenterology, and pulmonary, respectively. Nearly 18% of all patients that have a specialist and are treated and discharged from the ED present with a diagnosis related to their specialist's practice. This may indicate that there is a role for specialty service to play in decreasing some ED utilization that may be appropriate for the out-patient clinical setting. By focusing attention on specific specialties and interventions targeted during office hours, there may be an opportunity to decrease ED utilization. [ABSTRACT FROM AUTHOR]

Despite a series of federal laws aimed at ensuring parity in insurance coverage of treatment for mental health and general health conditions, patients with mental disorders continue to face discrimination by insurers. This inequity is often due to overly restrictive utilization review criteria that fail to conform to accepted professional standards. A recent class action challenge to the practices of the largest U.S. health insurer may represent an important step forward in judicial enforcement of parity laws. Rejecting the insurer's guidelines for coverage determinations as inconsistent with usual practices, the court enunciated eight principles that defined accepted standards of care. [ABSTRACT FROM AUTHOR]

AbstractBACKGROUND:Disseminating information derived from systematic reviews is a fundamental step for translating evidence into practice.OBJECTIVE:To determine which features of dermatological SR are associated with systematic review dissemination, using citation rates as an indicator.METHODS:Dermatological systematic reviews published between 2008 and 2012 were obtained from Scopus, the ISI Web of Sciences and the Cochrane Skin Group. Bibliometric data of every systematic review were collected and analyzed.RESULTS:A total of 320 systematic reviews were analyzed. Univariable analysis showed that the journal impact factor, number of authors, and total references cited were positively associated with the number of citations. There was a significant difference in the median number of citations with regard to the corresponding author's country, type of skin disease, type of funding, and presence of international collaboration. Cochrane reviews were significantly associated with a lower number of citations. Multivariable analysis found that the number of authors, number of references cited and the corresponding author from United Kingdom were independently correlated with many citations. Cochrane systematic reviews tended to be independently associated with a lower number of citations.CONCLUSIONS:Citation number to systematic reviews may be improving by increasing the number of authors, especially collaborative authors, and the number of cited references. The reasons for the association of Cochrane SRs with fewer citations should be addressed in future studies.

Cancer continues to evolve from a terminal diagnosis to a chronic medical condition. With improved survivorship rates, opportunities exist to deliver rehabilitation care throughout the oncology continuum. By definition, inpatient rehabilitation is generally considered postacute care and is provided either in inpatient rehabilitation facilities, in skilled nursing facilities, or in long-term care hospitals. Each institution is subject to specific regulations and legislation that help define appropriateness for admission based on diagnosis, medical necessity, and functional need. However, these criteria may present barriers to access care for the oncology survivor. As the healthcare landscape changes, and reimbursement structures shift from fee-for-service to those that emphasize effectiveness and efficiency in care, inpatient rehabilitation has a unique opportunity to improve value in terms of outcomes and cost. With the implementation of the Improving Medicare Post-Acute Care Transformation Act, standardization of measures throughout postacute care may allow for a more consistent approach to delivery of inpatient rehabilitation care. Further work will be necessary to define the parameters by which oncology survivors should be gauged in this framework. [ABSTRACT FROM AUTHOR]

What is a clinician to do when people needing medical care do not have access to consistent or sufficient health insurance coverage and cannot pay for care privately? Analyzing ethnographically how clinicians at a university-based transgender clinic in the United States responded to this challenge, I examine the U.S. health insurance system, insurance paperwork, and administrative procedures that shape transgender care delivery. To buffer the impact of the system's failure to provide sufficient health insurance coverage for transgender care, clinicians blended administrative routines with psychological therapy, counseled people's minds and finances, and leveraged the prestige of their clinic in attempts to create space for gender nonconforming embodiments in gender conservative insurance policies. My analysis demonstrates that in a market-based health insurance system with multiple payers and gender binary insurance rules, health care may be unaffordable, or remain financially challenging, even for transgender people with health insurance. Moreover, insurance carriers' "reliance" on clinicians' insurance-related labor is problematic as it exacerbates existing insurance barriers to the accessibility and affordability of transgender care and obscures the workings of a financial payment model that prioritizes economic expediency over gender nonconforming health. [ABSTRACT FROM AUTHOR]

This descriptive study examines the provision of chaplaincy services to veterans who sought health care at a Department of Veterans Affairs (VA) Medical Center following a suicide attempt. A system-wide VA database of suicidal behavior was used to identify a cohort ofn = 22,701 veterans who survived a suicide attempt. Next, an electronic review of VA clinical records found thatn = 7,447 (32.8%) received chaplaincy services in the 30 days following their attempt. Of this group, the overwhelming majority of first chaplaincy encounters took place in in-patient settings:n = 6890 (92.5%). First chaplaincy encounters most often occurred 1–7 days following the attempt:n = 5,033 (67.6%). Most chaplaincy service users had only one chaplaincy encounter:n = 3,514 (47.2%). The findings suggest that, at VA Medical Centers, a relatively sizeable percentage of suicide attempt survivors have contact with chaplaincy services. Additional research is needed to ascertain if chaplaincy services yield any therapeutic benefit for this group. [ABSTRACT FROM PUBLISHER]

Objective: This study aims to evaluate the prevalence of inappropriate hospital stays in a tertiary hospital in Shanghai, identify the causes for the inappropriateness and analyze the predictors.Design: A retrospective review of medical records.Setting: The cardiology and the orthopedics departments of a tertiary hospital in Shanghai, China.Participants: About 806 patients discharged from the cardiology or the orthopedics department of a tertiary hospital from March 2013 to February 2014.Interventions: Two reviewers audited 8396 hospital days of the cardiology department (n = 3606) and the orthopedics department (n = 4790) by adopting the Chinese Version of the Appropriateness Evaluation Protocol. Univariate and multivariate analysis were adopted to identify the predictors of higher levels of inappropriateness produced by internal causes.Main Outcome Measure: The prevalence of inappropriate hospital days.Results: It was found that 910 (25.2%) and 1940 (40.5%) hospital days were judged to be inappropriate in the cardiology and the orthopedics departments, respectively; and 753 (20.9%) and 1585 (33.1%) of these inappropriate hospital days were due to internal reasons, respectively. Awaiting tests, surgery or discharge were determined to constitute the main causes of inappropriateness for both departments. The predictors of higher levels of inappropriateness in the cardiology department were younger age, self-pay, outpatient admission and inappropriate admission. Self-pay, surgical and/or first-time admission patients exhibited the highest levels of inappropriateness in the orthopedics department.Conclusions: The rates of inappropriateness in the involved departments were relatively high. Further interventions should be designed and implemented, accordingly. [ABSTRACT FROM AUTHOR]

Background and Aim: In attention to pressing need to cost containment and service efficiency, laboratory services serve as a central locus for controlling health care expenditure. This study intents to investigate proportion of laboratory utilization in Iran to pave the way for future interventions. Materials and Methods: A cross-sectional study was conducted to investigate the proportion for laboratory utilization through the retrospective analysis of 384 medical records at the tertiary care Kashan University Hospital Shahid Beheshti. To pave the way for future intervention, over utilization tests were classified into two categories, inappropriate and resulted in laboratory errors. Results: Nine thousand five hundred forty one laboratory tests were ordered, 2522 (26.40%) of the tests were inappropriate and 143 (1.5%) of the over utilization tests have occurred due to laboratory testing cycle errors. According to reviewers' judegment relevancy to medical intervention was considered as the most accepted appropriateness criteria 5012 (52.53%) for laboratory tests Conclusion: Since, the laboratory tests over utilization is multifactorial, forming a multidisciplinary team including physicians, nurses, laboratory staff, medical education experts, health care management and health information technology staffs in terms of Utilization Committee to develop more targeted strategy based on root cause analysis of over utilization behavior seems necessary. [ABSTRACT FROM AUTHOR]

Purpose: Optimizing the utilization of CT pulmonary angiogram (CTPA) for the diagnosis and workup of acute chest pain can provide an opportunity to reduce unnecessary radiation and health care system expense.Methods: An attempt to improve CTPA utilization began by measuring overall department and clinician-specific utilization. This was bolstered by retrospectively evaluating patient charts for pulmonary embolism scoring criteria and D-dimer utilization so as to better understand gaps in diagnostic workup. The department-wide and individualized metrics were then provided to each emergency department clinician and differences between the pre- and postintervention data were evaluated.Results: The percentage of positive CTPAs did not change significantly at 8.7% and 9.2% in the pre- and postintervention groups, respectively. Similarly, the workup of patients based on retrospective PERC and Wells-score criteria did not significantly improve after the intervention. However, the percentage of CTPAs ordered on low D-dimer patients did decrease significantly post-intervention. Further observational analysis uncovered marked variability in clinician ordering behavior and diagnostic rates.Conclusions: Overall, such an intervention seems to have a limited, though not insignificant, impact on the workup of suspected pulmonary embolism. Calculating provider-specific utilization metrics allows both the radiologist and clinician to better understand opportunities to improve health care delivery. [ABSTRACT FROM AUTHOR]

Purpose: Limited resources, neurointensivists, and neurologic intensive care unit (neuro-ICU) beds warrant investigating models for predicting who will benefit from admission to neuro-ICU. This study presents a possible model for identifying patients who might be too well to benefit from admission to a neuro-ICU. Methods: We retrospectively identified all patients admitted to our 16-bed neuro-ICU between November 2009 and February 2013. We used the Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database to identify patients who on day 1 of neuro-ICU admission received 1 or more of 30 subsequent active life-supporting treatments. We compared 2 groups of patients: low-risk monitor (LRM; patients who did not receive active treatment [AT] on the first day and whose risk of ever receiving AT was ≤10%) and AT (patients who received at least 1 of the 30 ICU treatments on any day of their ICU admission). Results: There were 873 (46%) admissions in the LRM group and 1006 (54%) admissions in the AT group. The ICU length of stay in days was 1.7 (±1.9) for the LRM group versus 4.5 (±5.5) for the AT group. The ICU mortality was 0.8% for the LRM group compared to 14% for the AT group (odds ratio [OR] = 17.6; 95% confidence interval [CI], 8.2-37.8, P < .0001). Hospital mortality was 1.9% for the LRM group compared to 19% for the AT group (OR = 9.7; 95% CI, 5.8-16.1, P < .0001). Conclusion: The outcome for LRM patients in our neuro-ICU suggests they may not require admission to neurologic intensive care. This may provide a measure of neuro-ICU resource use. Improved resource use and reduced costs might be achieved by strategies to provide care for these patients on floors or intermediate care units. This model will need to be validated in other neuro-ICUs and prospectively studied before it can be adopted for triaging admissions to neuro-ICUs. [ABSTRACT FROM AUTHOR]

Background: Considering the role of laboratory tests as a central part of controlling health expenditure, this study intends to investigate laboratory tests overutilization in Iran to pave the way for future interventions. Methods: Inappropriate laboratory utilization was reviewed in a cross-sectional survey through the retrospective analysis of 384 medical records at a tertiary center. To pave the way for future intervention, overutilization tests were classified into two categories, inappropriate and inefficient, and then they were analyzed. Frequency analysis was used to analysis patient's age, gender, hospital wards, length of stay, and diagnosis as well as inappropriate test and inefficient tests. Results: A total of 143 (1.50%) of the tests were inefficient and was ordered due to laboratory errors including hemolysis, inefficient sampling, or absurd results. 2522 (26.40%) of the tests were inappropriate and stem from failure to meet medical/clinical appropriateness criteria. Conclusion: Whereas, inappropriate test ordering was more frequent than inefficient tests, the initial improvement strategy should focus on physicians' test ordering behavior through conducting proper teaching strategies, ongoing audit and educational feedback, implementing health information technology tools and employing laboratory practice guidelines (LPGs) and testing algorithms. Conducting continuous quality improvement cycle for laboratory services and training of personnel involved in blood sampling is recommended for inefficient tests. [ABSTRACT FROM AUTHOR]

Background: The present study is a utilization review of outpatient services offered by specialists and underlying social factors among urban families in Fars Province, Iran. Methods: The present study conducted among 1900 residents in key areas of Fars Province in January 2013. Sampling was carried out through a three-step method, which was designed based on utilization of health services survey. Data were analyzed using statistical tests. Results: About a quarter of the sample group expressed the need for outpatient services of specialists, of whom about 83% received medical attention of a specialist. Among the main reasons for not referring to specialists were financial issues as the top reason followed by refusal to visit the physician, long distances and high costs of the services. Conclusion: About 17% of the participants who needed outpatient services of specialists failed to receive the service. This indicates the necessity of measurements to improve the access to outpatient services of specialists among different social groups. [ABSTRACT FROM AUTHOR]

Criteria to define an episode of care in children's mental health services are needed. Various criteria were applied to 5 years of visit data from children 4-11 years (N = 5,206) at their first visit to 1 of 3 children's mental health agencies. A minimum of 3 visits with 180 days between episodes optimized agreement with other dates (e.g., telephone intake assessment) marking the start and end of an episode, and clinician-rated number of episodes. Grouping visits into episodes provides a clearer representation of how services are distributed over extended periods of time, facilitating research and enhancing accuracy in service planning. [ABSTRACT FROM AUTHOR]

Many psychotherapists may not remember an age when the landscape of clinical practice did not include managed care organizations (MCOs). As peer reviewers for a large health services company, we have found that utilization review is still perceived as onerously as it once actually was. To help practitioners save time and advocate more effectively for mental health outpatients, we provide guidance on the peer review process for psychotherapists who interact with MCOs, either as members of insurance networks or as psychotherapists for self-pay patients who, in turn, must justify to third-party payers the medical necessity of treatment in order to obtain reimbursement themselves. We describe the process of utilization review, the peer review being a central component, followed by the specific elements of medical necessity that pertain to outpatient care. Finally, we discuss specific case examples to highlight how providers can advocate most effectively for treatment that is medically necessary. [ABSTRACT FROM AUTHOR]

Background: Laboratory utilization management describes a process designed to increase healthcare value by altering requests for laboratory services. A typical approach to monitor and prioritize interventions involves audits of laboratory orders against specific criteria, defined as rule-based laboratory utilization management. This approach has inherent limitations. First, rules are inflexible. They adapt poorly to the ambiguity of medical decision-making. Second, rules judge the context of a decision instead of the patient outcome allowing an order to simultaneously save a life and break a rule. Third, rules can threaten physician autonomy when used in a performance evaluation. Methods: We developed an alternative to rule-based laboratory utilization. The core idea comes from a formula used in epidemiology to estimate disease prevalence. The equation relates four terms: the prevalence of disease, the proportion of positive tests, test sensitivity and test specificity. When applied to a laboratory utilization audit, the formula estimates the prevalence of disease (pretest probability [PTP]) in the patients tested. The comparison of PTPs among different providers, provider groups, or patient cohorts produces an objective evaluation of laboratory requests. We demonstrate the model in a review of tests for enterovirus (EV) meningitis. Results: The model identified subpopulations within the cohort with a low prevalence of disease. These low prevalence groups shared demographic and seasonal factors known to protect against EV meningitis. This suggests too many orders occurred from patients at low risk for EV. Conclusion: We introduce a new method for laboratory utilization management programs to audit laboratory services. [ABSTRACT FROM AUTHOR]

Occupational therapy may significantly improve cancer survivors’ ability to participate in activities, thereby improving quality of life. Little is known, however, about the use of occupational therapy services by adults with cancer. The objective of this study was to understand what shapes patterns of occupational therapy use to help improve service delivery. We examined older (age >65 yr) adults diagnosed with breast, prostate, lung, or melanoma (skin) cancer between 2004 and 2007 (N = 27,131) using North Carolina Central Cancer Registry data linked to Medicare billing claims. Survivors who used occupational therapy within 1 yr before their cancer diagnosis were more likely to use occupational therapy after diagnosis but also experienced the highest levels of comorbidities. Survivors with Stage 4 cancers or lung cancer were less likely to use occupational therapy. These findings suggest possible disparities in utilization of occupational therapy by older adults with cancer. [ABSTRACT FROM AUTHOR]

Efficiently managing laboratory test utilization requires both ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients. After the difficult clinical decision is made to define the patients that do and do not need a test, a wealth of interventions are available to the clinician and laboratorian to help guide appropriate utilization. These interventions are collectively referred to here as the utilization management toolbox. Experience has shown that some tools in the toolbox are weak and other are strong, and that tools are most effective when many are used simultaneously. While the outcomes of utilization management studies are not always as concrete as may be desired, what data is available in the literature indicate that strong utilization management interventions are safe and effective measures to improve patient health and reduce waste in an era of increasing financial pressure. [ABSTRACT FROM AUTHOR]

Objectives: Many nonpathologists and some pathologists consider utilization review essential to laboratory quality improvement, but (1) confusion surrounding the definition of "appropriate" laboratory utilization, (2) the reliance on manual chart review, and (3) a lack of leadership have contributed to its unstandardized implementation. How the solutions to these barriers have evolved since the 1950s is described. Methods: A systematic literature review is used. Results: Current literature largely defines inappropriate laboratory utilization as any test order in violation of a guideline produced by a government or professional society. Audits performed without manual chart review (ie, database query) have dramatically increased since the mid-1990s. Most utilization audits do not involve any author with a pathology or laboratory medicine affiliation. Conclusions: Literature consensus defining "inappropriate" utilization combined with the adoption of database technology has removed key obstacles to utilization reviews. Leadership is needed to unify and benchmark laboratory utilization. [ABSTRACT FROM AUTHOR]

Purpose: Substantial variability exists in bladder exstrophy care, and little is known about costs associated with the condition. We define the care patterns and first year cost for patients with bladder exstrophy at select freestanding pediatric hospitals in the United States. Materials and Methods: We used the Pediatric Health Information System database to identify patients with bladder exstrophy born between January 1999 and December 2010 who underwent primary closure in the first 120 days of life. Demographic, surgical, postoperative and cost data for all encounters were assessed. Multivariate linear regression was used to examine the association between patient, surgeon and hospital characteristics and costs. Results: Of the 381 patients who underwent primary closure within the first 120 days of life 279 (73%) did so within the first 3 days of life. A total of 119 patients (31%) underwent pelvic osteotomy, including 51 of 279 (18%) who underwent closure within the first 3 days of life, 38 of 67 (56%) who underwent closure between 4 and 30 days of life, and 30 of 35 (86%) who underwent closure between 31 and 120 days of life (p = 0.0017). Median inflation adjusted, first year cost in United States dollars per patient was $66,577 (IQR $45,335 to $102,398). Presence of nonrenal comorbidity and completion of primary closure after 30 days of life increased first year costs by 24% and 53%, respectively. Increased post-closure length of stay was associated with greater costs. Conclusions: At select freestanding United States pediatric hospitals the majority of bladder exstrophy closures are performed within the first 3 days of life. Most, but not all, patients undergoing closure after the neonatal period undergo osteotomy. The presence of nonrenal comorbidity and increased postoperative length of stay are associated with greater costs. [ABSTRACT FROM AUTHOR]

Background. Medical transport using helicopter emergency medical services (HEMS) has rapidly proliferated over the past decade. Because of issues of cost and safety, appropriate utilization is of increasing concern. Objective. This study sought to describe the medical appropriateness of HEMS transports, using established guidelines, in a large national patient cohort. Methods. A review was performed of all flights designated as inappropriate by a large national air medical company, Air Evac EMS Inc. (which operates Air Evac Lifeteam [AEL]), for the period from January 1, 2009, through December 31, 2009. Every flight was reviewed initially through a resource utilization process as well as a utilization review process. Medical appropriateness review criteria were derived from the Medicare Benefit Policy Manual and industry guidelines outlined by the Commission on Accreditation of Medical Transport Systems (CAMTS), Air Medical Physicians Association (AMPA) position papers, the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) Guidelines for Field Triage, and published clinical peer-reviewed articles, as well as previous interactions with Medicare contractors and reimbursement appeal decisions. Higher scrutiny was given to flights of <30 or >100 miles. Records indicating a possible inappropriate flight (i.e., review criteria were not satisfied, but special circumstances existed) were further reviewed by a senior quality assurance/quality improvement (QA/QI) nurse and/or senior medical director and were categorized. Results. During the study period, 27,697 flights were completed and reviewed, with 582 (2.1%) flights identified for further review by a senior QA/QI nurse and/or senior medical director. Of those, 367 (1.3%) were determined to be medically inappropriate flights. Inappropriate flights were most often on-scene flights (59.9%), were most often for adult patients (92.9%; median age 56.9 years; 25-75% interquartile range 42-75 years), and most often represented medical diagnoses (57.8%). Conclusions. Based on established criteria, only 1.3% of total flights were determined to be inappropriate. This large national cohort demonstrated compliance with current industry standards. [ABSTRACT FROM AUTHOR]

Background We reviewed the data on external histopathology review for patients referred to our institution for sentinel lymph node biopsy ( SLNB) associated with melanoma, Merkel cell carcinoma and adnexal carcinoma. Methods We calculated the incidence of external histopathology review and the rate of discordance between internal and external histopathology diagnoses between January 1, 2010 and February 28, 2011. We conducted an anonymous poll of our community pathologists' experience with external histopathology review prior to SLNB. Financial charges and payments from 10 Medicare patients who underwent SLNB were obtained from our hospital's finance department. Results Sixty-eight cases were identified (63 melanomas, 4 Merkel cell carcinomas and 1 spiradenocarcinoma). The external histopathology was reviewed as part of the patient's care in 14 of 68 cases. In 3 of 14 reviewed cases, SLNB was deemed unnecessary. Nine of eleven community pathologists reported reviewing external histopathology material in less than 11% SLNB patients in their hospitals. The average Medicare reimbursement for SLNB and secondary pathology review was $5738 and $80 respectively. Conclusions Our data show that review of external cutaneous histopathology diagnoses on patients referred for SLNB is uncommon in our practice area, but is cost-effective and should be required to reduce unnecessary treatment. [ABSTRACT FROM AUTHOR]

PURPOSE. Recently, home health services have been a topic of increasing interest. Occupational therapy practice and utilization patterns in home care have not been the subject of recent research. METHOD. I examined 65 publications addressing current occupational therapy practice in U.S. home health. Articles were analyzed to uncover factors influencing occupational therapy utilization and practice. RESULTS. Results indicate that research has looked at a variety of typologies and efficacy measures for occupational therapy in home care. However, occupational therapy utilization and practice patterns in home health do not appear to be entirely consistent with research. I identify factors explaining this inconsistency and make research and practice recommendations. CONCLUSION. Results suggest that system challenges limit the utilization and practice of occupational therapy to deliver expected outcomes in home health practice. [ABSTRACT FROM AUTHOR]

Objective To develop and validate a list of criteria to assess the causes of inappropriate hospital days for patients admitted to rehabilitation centres and sub-acute care units. Design The tool was developed by a multidisciplinary panel of 33 experts, using a formalized consensus method. It collects both the needs of patients (distinguishing healthcare needs (9 criteria) and accommodation needs (9 criteria)) and the reasons for inappropriateness (19 criteria). Inappropriate days were identified using the tool to assess appropriateness of hospital days validated previously. Reliability was studied by measuring agreement between two independent simultaneous ratings. Setting The validation study was performed on a randomized sample of 576 hospital days from 22 wards in France. Main Outcome Measures Inter-rater reliability was evaluated using the κ-statistic and prevalence-adjusted and bias-adjusted kappa (PABAK). Results For patient accommodation needs, the inter-rater reliability was estimated by a κ-value of 0.80 (95% confidence interval (95% CI) 0.66–0.92) and a PABAK of 0.80 (95% CI 0.63–0.91). There was good agreement on the reasons for inappropriateness, with κ-values from 0.30 to 0.60 and PABAK from 0.46 to 0.69. The κ-coefficient varied from 0.33 to 0.49 for the assessment of patient healthcare needs, with PABAK ranging from 0.49 to 0.72. Conclusions The instrument is suitable and valid to assess the causes of inappropriate hospital days in rehabilitation centres and sub-acute care units. The study showed that the tool can be easily used by healthcare workers, which makes it useful for quality improvement. [ABSTRACT FROM PUBLISHER]

The article discusses the results of a study on the clinical outcome of using high-frequency oscillation in treating adult patients with acute lung injury/acute respiratory distress syndrome. The study shows that patients experienced improvement in their acute respiratory syndrome and severe hypoxemia after treating with high-frequency oscillation. About 5.3 percent of patients suffered complications. The reasons for terminating the use of high-frequency oscillation are mentioned.

Purpose: Since 2006, the working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine, in cooperation with the working group Nuclear Cardiology of the German Cardiac Society, has been surveying the utilization and technical realization of myocardial perfusion scintigraphy (MPS) in Germany. This paper presents the results of the reporting year 2009. Methods: A total of 291 centres participated in the inquiry, including 179 private practices (PP), 86 hospitals (HO) and 26 university hospitals (UH). Results: MPS of 98,103 patients were reported. The MPS numbers per million population (pmp) were estimated at 2,360; 76% of the MPS were performed in PP, 17% in HO and 7% in UH. The ratio of MPS to coronary angiography to revascularization was 0.5 to 2.3 to 1. Data from 134 centres which participated in the surveys from 2005 to 2009 showed a decrease in MPS utilization of 2.2%. Nearly half of the MPS were requested by ambulatory care cardiologists. Of all MPS studies, 89% were conducted with Tc perfusion tracers. Ergometry was the preferred stress test (69%). Adenosine was used in 16%, adenosine + exercise in 7%, dipyridamole in 3%, dipyridamole + exercise in 5% and dobutamine in <1%. Gated single proton emission computed tomography (SPECT) acquisition was performed in 56% of all rest MPS and in 56% of all stress MPS. Both rest and stress MPS were ECG gated in 41%. Only 33% of the centres always performed a quantification of the perfusion studies, whereas 51% did not apply any quantification; 4% of the MPS studies were corrected for attenuation, and 17 centres used transmission sources of 12 CT-based systems. Conclusion: A scan activity of 2,380 MPS pmp is in the upper third of the European range. The ratios to coronary angiography and to revascularization suggest that angiography dominates diagnosis and management of coronary artery disease (CAD). The clinical and technical realizations reveal that the predominant goals of further trainings to optimize MPS are in the field of gated SPECT and quantitative perfusion SPECT. [ABSTRACT FROM AUTHOR]

Purpose: Radiology benefit managers (RBMs) are widely used by private payers to manage the utilization of imaging services through prior authorization, and they have been proposed for use in the Medicare program. The authors created a framework for evaluating the impact of key parameters on the ability of RBMs to lower costs and used decision-analytic modeling to simulate the net impact of RBMs on health care costs under uncertainty from a societal perspective. Methods: The authors'' model of a “typical” RBM''s prior authorization process used base-case values for each parameter (utilization rate and costs for MR, CT, and PET imaging; physician and staff time spent in complying with RBM requirements; approval and denial rates; and RBM fees to insurers) drawn from published data and the experience of a large, academic institution. Different values were tested in the sensitivity analysis to account for uncertainty in the parameter estimates. A hypothetical 100,000-member private health plan with an imaging utilization rate of 135 per 1,000 members per year was assumed. Results: Under the authors'' base-case scenario, in which RBMs have no net impact on costs, they estimated that 28% ($182,066/$640,263) of the projected RBM-related savings are shifted to providers. RBMs were cost saving in 45% of simulations, and 95% of simulations fell between a cost decrease of $397,880 and a cost increase of $341,991. The probability of an initial approval by the RBM, the RBM''s fee, and the imaging utilization rate and associated charges had the largest influence on the results. Conclusions: The authors'' models shows that RBMs shift significant costs to physicians and that their net impact on societal costs depends on parameters for which supporting data are incomplete. [Copyright &y& Elsevier]

This study evaluates the impact of pediatric uninary tract infection (UTI)s on the economy and inpatient healthcare utilization in the USA. A retrospective analysis of patient demographics and hospital economics was performed on children less than 18 years of age admitted with a UTI between 2000 and 2006 using the Healthcare Cost and Utilization Project Kids' Inpatient Database. Our results were stratified as follows. Hospital admissions-nearly 50,000 children/year were admitted with a UTI. Pediatric UTIs represented 1.8% of all pediatric hospitalizations. Seventy-three percent of patients were female and 40% were under 1 year of age. Payer information-from 2000 to 2006, pediatric insurance coverage shifted from the private sector to the public sector. Hospital cost-in 2000, estimated hospital costs for UTIs were $2,858 per hospitalization and rose to $3,838 by 2006. Mean hospital charges increased from $6,279 to $10,489 per stay. By 2006, aggregate hospital charges exceeded $520 million. Our results indicate that UTIs are among the most common pediatric admission diagnoses. Hospitalization is more common in females and younger children. Since 2000, hospital charges for UTIs increased disproportionately to hospital costs. Over time, more children hospitalized with a UTI depend on public agencies to cover healthcare expense. More efforts are needed to evaluate cost-effective strategies for evaluation and treatment of UTIs. [ABSTRACT FROM AUTHOR]

Objective: To review the use of evidence-based practices in the care of mothers who died or had severe morbidity attending public hospitals in two Latin American countries.Methods: This study is part of a multicenter intervention to increase the use of evidence-based obstetric practice. Data on maternal deaths and women admitted to intensive care units whose deliveries occurred in 24 hospitals in Argentina and Uruguay were analyzed. Primary outcomes were use rates of effective interventions to reduce maternal mortality (MM) and severe maternal morbidity (SMM).Results: A total of 106 women were included: 26 maternal deaths and 80 women with SMM. Some effective interventions for severe acute hemorrhage had a high use rate, such as blood transfusion (91%) and timely cesarean delivery (75%), while active management of the third stage of labor (25%) showed a lower rate. The overall use rate of effective interventions was 58% (95% CI, 49%-67%). This implies that 42% of the women did not receive one of the effective interventions to reduce MM and SMM.Conclusion: This study shows a low use of effective interventions to reduce MM and SMM in public hospitals in Argentina and Uruguay. Dissemination and implementation of evidence-based practices must be guaranteed to effectively achieve progress on maternal health. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: This study presents a new model for identifying patients who might be too well to benefit from intensive care unit (ICU) care. Patients and Methods: Intensive care unit admissions in 2002 to 2003 were used to develop a model to predict whether patients monitored on day one would receive one or more of 33 subsequent active life-supporting treatments. Accuracy was assessed by testing the model in a subsequent cohort of admissions in 2004 to 2006. We then assessed the frequency of active treatment among monitor patients at a low (<10%) risk for active life-supporting therapy on ICU day 1. Results: Among 28 847 ICU monitor admissions in 2004 to 2006, 3153 patients (11.0%) were predicted to receive active treatment; 3296 (11.5%) actually did. There were 17 720 admissions with a low (<10%) risk for receiving subsequent active life-supporting treatment; 1238 (7.0%) received subsequent active treatment. Hospital mortality (2.5%) and mean ICU stay (1.8 days) suggests that most of these patients did not require ICU care. Conclusions: The outcome for low-risk monitor patients suggest they may be too well to benefit from intensive care. The frequency of low-risk monitor admissions provides a measure of ICU resource use. Improved resource use and reduced costs might be achieved by strategies to provide care for these patients on floors or intermediate care units. [Copyright &y& Elsevier]

Introduction. Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport. Methods. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms “triage”; “utilization review”; “health services misuse”; “severity of illness index,” and “trauma severity indices.” Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated. Results. From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 × 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823. Conclusion. The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers. [ABSTRACT FROM AUTHOR]

Background. Our state has consensus guides for helicopter emergency medical services (HEMS) scene dispatch, based on physiologic, anatomic, and special criteria (e.g., ejection from a vehicle, age < 10 or > 55 years). There has been much attention paid to improving HEMS triage criteria, but less focus on whether current HEMS uses meet existing criteria. Objectives. To assess a HEMS program's compliance with regional air medical dispatch guidelines and to identify factors associated with noncompliant flights. Methods. Using chart review and discussion with referring agencies, we conducted a consecutive case review of a HEMS program's initial 100 flights in one year (2005), collecting data pertinent to triage, prehospital times, and hospital course. Analysis (p = 0.05) of the outcome “met triage criteria” (MTC) used Kruskal-Wallis and Fisher's exact tests. Logistic regression, reporting odds ratios (ORs) with 95% confidence intervals (CIs), was used to adjust for covariates while assessing predictors of the dichotomous outcome MTC. The predictors assessed included demographics, advanced life support (ALS) scene presence, and whether transports occurred during rush hours (0700-1000 and 1600-1900). Results. The 100 patients (98 blunt trauma; 73% male) from four Massachusetts emergency medical services (EMS) regions (n = 94) and New Hampshire (n = 6) were classified as MTC in 73% of cases. Physiologic criteria were met in 19% of cases (they were the sole criterion met in one case), anatomic criteria in 49% (sole criterion n = 24), and special criteria in 67% (sole criterion n = 15). There was no association between MTC status and age (p = 0.98), gender (p = 0.39), rush-hour transport (p = 0.81), or ALS-trained ground EMS presence on scene (p = 0.98). Analysis adjusting for transport distance and injury mechanism identified an association between EMS region and MTC transport status (p = 0.006); regions' likelihoods of MTC proportions ranged from 50% to 94%. Conclusion. Despite promulgation of consensus guidelines, nearly a fourth of HEMS transports were non-MTC. Wide interregional variation in the likelihood of MTC HEMS use provides a focus for further research/education. Regional systems should strive not only for the refinement of, but also the compliance with, HEMS triage guidelines. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although noninvasive positive pressure ventilation (NPPV) improves outcomes in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), it may be underutilized outside the controlled trial setting. Purpose: The purpose of this study is to determine the proportion of patients who met criteria for a trial of NPPV but were emergently intubated and mechanically ventilated without receiving a trial of NPPV. Methods: We retrospectively reviewed charts of patients who were intubated and ventilated or who received NPPV on admission to one intensive care unit and who had an intensive care unit admitting diagnosis of either exacerbation of COPD or CHF during the period from November 1998 to July 2003. Results: Of the 243 patients who had an admitting diagnosis of COPD or CHF, 59 (24.3%) met explicit criteria for a trial of NPPV. Only 20 (33.9%) of 59 had a trial of NPPV. The remaining 39 (66%) of 59 did not receive a trial of NPPV and were intubated. Interpretation: Nearly two thirds of patients who appeared to meet criteria for NPPV did not receive a trial of this intervention. There is an opportunity to improve the use of NPPV in these patients. Systematic knowledge translation strategies such as guideline implementation and interactive educational interventions may optimize the appropriate use of NPPV. [Copyright &y& Elsevier]

Short, unnecessary hospitalizations are the largest contributor to erroneous Medicare payment. A team of medical, nursing, case management, and coding and billing professionals used process improvement techniques to reduce inappropriate 1-day admissions among 20 hospitals with high 1-day-stay utilization. Interventions included performance feedback, root cause analyses, process redesign, monthly progress monitoring, and quarterly pattern analyses. Over a 6-month period, the unweighted average admission error rate was reduced from 39% to 21% (p < .01). An estimated 1,396 1-day stays were prevented or denied payment, resulting in an annual savings of $6 million for Medicare's Hospital Insurance Trust Fund. [ABSTRACT FROM AUTHOR]

Substitution of hospital staff performing concurrent utilization review (CUR) was evaluated using a production process framework. There were no differences in the number of reimbursement denials or denied days among 4 job classifications of hospital staff performing CUR, indicating that educational preparation of staff did not affect outcomes. The implications are that hospitals could substitute assistive staff in place of registered nurses to complete the CUR function, potentially increasing the availability of professional nurses. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Diabetes is a chronic illness and have relatively high prevalence. Glycemic control is fundamental to the management of diabetes. Hemoglobin A1c (HbA1c) is a commonly used laboratory test to monitor glycemia and to manage diabetes. This study aimed to assess the appropriateness of the frequency of HbA1c test order with respect to the commonly approved guidelines for monitoring glycaemia of patients. Methods To assess the rate of inappropriate test orders, laboratory records of HbA1c tests ordered between 2002 and 2004 were evaluated. Inappropriate orders were defined as any order for a given patient that takes place within a 29- or 89-day-period following the previous HbA1c order. The effects of various parameters, like ordering clinics, the first HbA1c level, or the on-line availability of test results on test ordering were evaluated. Results Evaluation of test intervals showed that 10.3% of all orders and 33.8% of the inpatients’ orders were performed within 29 days, 35.5% of all orders and 55% of the inpatients’ orders were within 89 days. Conclusions Inappropriate laboratory utilization of HbA1c testing is very common especially in the inpatient clinics. We think that the application of the guidelines may decrease unnecessary health expenditure. [ABSTRACT FROM AUTHOR]