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Purpose/objectives: The Centers for Medicare & Medicaid Services funded a project in six western states to decrease the payment error rate in short-stay admissions (< or =2 days) and decrease the number of inpatient discharges for short stays. Seventeen hospitals were recruited to implement the Case Management Assignment Protocol (CMAP), which standardizes the decision-making process at admission, thereby increasing the number of hospitalized patients assigned to the correct status of inpatient or observation., Primary Practice Setting: Acute care hospitals., Findings/conclusions: Based on the decrease in unnecessary admissions and the relationship between use of the protocol and correct admission status, the project demonstrated that the CMAP was effective in ensuring that patients were placed in the appropriate status., Implications for Case Management Practice: 1. Case managers can play a key role in correct assignment of patient status through the use of the CMAP. 2. Hospitals that were successful in implementing the protocol had highly involved senior management, stable corporate environments, physician buy-in, physician champions, policies for mandatory use within the facilities, support from all team members, and "out-of-the-box" thinking for case management coverage. 3. Staffs at hospitals that implemented the protocol indicate they are well positioned for the Recovery Audit Contractor program, which began as a 3-year demonstration project and is now being implemented. It will be in place nationally by 2010.

Purpose/objectives: Each year in the United States, more than 4.4 million patients with chest pain (DRG 143) present to emergency departments. Many of these admissions do not have documented justification to support an acute inpatient admission. Two Medicare quality improvement organizations identified this as a common theme, and special projects were designed and implemented to reduce the incidence of inappropriate hospital admissions for chest pain in their states (Florida and Arizona). One commonality to both intervention projects was use of the case management protocol (CMP)., Primary Practice Setting(s): Acute care hospitals., Findings/conclusions: As a result of the special projects, in Florida, there was a 67% reduction in projected admission denials and a 48% overall reduction in chest pain discharges among participating hospitals. In Arizona, the rate of inappropriate 1-day admissions for DRG 143 was reduced 42% from baseline to remeasurement for the participating hospitals; the absolute number of DRG 143 one-day admissions was reduced by 90%. Of the 10 Arizona hospitals that used the case management protocol, 8 met or exceeded the project goals., Implications for Case Management Practice: 1. Although outpatient observation admission status has been around for many years, there remain confusion and resistance to its use. The definitions of clinical status, level of care, and patient status are not well defined, and choosing the correct pathway for each patient can be complex. This article helps clarify "Observation vs. Inpatient"admission status and details lessons learned in reducing resistance. 2. Use of the case management protocol requires a hospital to define case management roles and responsibilities. This is a critical but often neglected task. 3. Use of case management for determining correct patient status is growing. With new Centers for Medicare & Medicaid Services initiatives, including the recovery audit contractors, case management is a viable solution to maintaining the fiscal health of hospitals.

The Florida Medicare quality improvement organization implemented a case management project with 20 acute care hospitals to reduce unnecessary Medicare admissions. The project called for hospitals to implement a protocol to assign patients to observation or inpatient admission status. Results of the project showed a 67% reduction in the denial rate for the participating facilities. This relative reduction in denial rates was nearly 3 times greater for the participating facilities as compared to the control facilities. The protocol can easily be adopted by hospitals.

Objective: Guidelines for emergency treatment of stroke are not always known or followed. Florida Medical Quality Assurance, Inc. collaborated with hospitals to determine how closely the current American Heart Association (AHA) and the Florida Agency for Health Care Administration (AHCA) guidelines were being followed and to improve compliance with these guidelines., Methods: Medical records of patients admitted for acute stroke to 32 hospitals were retrospectively reviewed for compliance with six quality indicators (QIs) on the basis of AHA and AHCA guidelines. Hospitals were provided feedback on their levels of guideline compliance, and they subsequently implemented measures to improve compliance. After 6 months, the records of patients admitted after the provision of feedback were reviewed for compliance with the same six QIs., Results: Compliance improved with regard to all QIs and was statistically significant for three of them., Conclusion: Feedback on performance, coupled with proactive collaboration with emergency department staff, resulted in improved compliance with the stroke guidelines.

A phase II study of diglycoaldehyde was conducted in 42 patients with malignant melanoma and soft tissue sarcoma. All patients received diglycoaldehyde at a dose of 2 g/m2 iv over 6 hours daily for 3 days. This was repeated every 28 days. Major toxic effects included phlebitis and azotemia, requiring dialysis in one patient. Of the 42 patients, 38 were evaluable for response. One objective response occurred in a patient with malignant melanoma. Diglycoaldehyde at this dose and schedule appears to have no role in the management of malignant melanoma or soft tissue sarcoma.

Sixteen women with advanced carcinoma of the cervix were treated with adriamycin and methotrexate. Median age on entry into the study was 51 years. Seven subjects were premenopausal, 7 postmenopausal, and 2 were within 2 years of their last menstrual period at the time of diagnosis. Median time of inclusion in the study was 3.3 months. Median survival from initial diagnosis thus far has been 39.0 months. Median survival from the institution of therapy has been 5.8 months. Of 16 evaluable patients the following results were obtained: no complete remissions (0%), 2 partial remissions (12.5%), 1 patient with stable disease (6.2%). When used in dosages which do not precipitate dangerous toxicity this therapy is not effective and in the opinion of the authors should be abandoned.

Patients with acute nonlymphocytic leukemia were randomized to receive remission induction therapy consisting of seven days of cytosine arabinoside and three days of daunorubicin ("7 + 3") or to receive the same regimen intensified by either the addition of 6-thioguanine or by extension of the administration of cytosine arabinoside to ten days. Additionally, all patients were randomized to receive or not to receive cotrimoxazole antibacterial prophylaxis during the remission induction phase. Neither an increase in intensity of chemotherapy nor the antibacterial prophylaxis increased the remission rate above the 53% for patients treated with the standard "7 + 3" regimen. The second part of this study addressed the issue of the utility of long-term maintenance chemotherapy. To this end, patients were randomized to discontinue all treatment after 8 months of maintenance chemotherapy or to continue maintenance therapy for a total of 3 years. Although there was a transient increase in the relapse rate for patients who discontinued therapy, the proportion of long-term remitters was identical in the two patient groups. Additionally, there is a suggestion of a survival advantage for patients randomized to discontinue all therapy at 8 months.