RESUMO
Objective: Utilization review is very important especially in universal coverage policy. In Siriraj Hospital the utilization review began in 2002, and the Department of Orthopaedic Surgery developed the indicators “ORTHOPAEDICS” to assess the appropriateness of medical utilization. This study is designed to study the effectiveness of medical utilization review by using indicators “ORTHOPAEDICS” in orthopaedics, public inpatients under universal coverage policy in terms of expenses, the appropriateness, length of hospital stay and the satisfaction of the patients. Methods: 301 orthopaedic inpatients were divided in 2 groups: Group A included 149 patients, 100 men and 49 women. Their average age was 32.7 years old. From June 1, 2003 – May 31, 2004, each patient was prospectively reviewed regarding their daily utilization in terms of expenses, appropriateness of medical utilization by using indicators “ORTHOPAEDICS”. Their length of hospitalization was measured, as well as and their satisfaction evaluated. Group B was the control which included 152 patients, 98 men and 54 women. Their average age was 34.8 years old. No intervention was performed and the data was collected only in expenses and the length of hospital stay for each patient retrospectively from June 1, 2002– May 31, 2003. The expenses and the length of hospital stay of both groups were compared and analyzed. The appropriateness in Group A was studied by using indicators “ORTHOPAEDICS” which were: O = Operation; R = Relative weight rate; T = Type of treatment; H = Hospital stay; O = Occurrence of complication; P = procedures; A = admission; E = expenses; D = drugs; I = Investigation; C = Care map according to CPG of 12 diseases; S = Satisfactions score from 0-10 minimum to maximum, by asking the patients about the satisfaction in term of results of treatment. Results: The total expenses per patient in group A was 24,566.74 baht but in group B was 30,484.53 baht. The expense in group A was 5,917.79 baht reduction which was statistically significant difference (P<0.05). The average length of hospital stay in group A was 8.24 days, whereas in group B was 10.93 days. It reduced 2.69 days after utilization review was implemented. The appropriateness of utilization was found in the procedures, drugs and investigation without inappropriateness (0%). The inappropriateness in admission was 26.9% because the physician forgot to take blood examination and laboratory investigation before admission and it was done in the ward without any effect the treatment. And the average satisfaction score in group A was 9.6. Conclusion: “ORTHOPAEDICS” was useful and helpful indicator to significantly reduce the expense per patient and the length of hospitalization without reducing patient satisfaction and quality of treatment.
RESUMO
OBJECTIVE: To assess agreement in detection of lumbar disc herniation (LDH) between limited and full protocol MRI. MATERIAL AND METHOD: 123 patients who requested lumbar MRI for diagnosis of disc herniation were assessed The full protocol MRI composed of sagittal T1-wi, sagittal T2-wi and axial T2-wi was performed on each patient. The sagittal T2-wi was selected as the limited protocol MRI. The limited and full protocols MRI of each patient were separately interpreted by three neuroradiologists to assess disc herniation and nerve root compression. The consensus results of limited and full protocol were compared. The diagnostic performance of each protocol was analyzed using surgery as the gold standard. RESULTS: There were 62 females and 61 males enrolled into the study between the age of 21-60 years old (means = 42.91 years). The duration of pain was 1-204 months (mean = 31.20 months). The degree of severity was mild in 23.58%, moderate 45.52% and severe 30.89% of cases. Thirty-three cases were operated on. For detection of LDH, the limited protocol gave the same interpretation results as the full protocol (0 = 1.04, 95%CI = 0.94, 1.14 with accepted range of 0.95-1.05). In nerve root compression, the limited protocol was not accurate as the full protocol (0 = 0.75, 95%CI = 0.87, 0.63). The sensitivity, specificity, accuracy, PPV, NPV, and LR+ in the surgical group of limited protocol in diagnosis of LDH were 82.61%, 80%, 81.82%, 90.48%, 60.67%, 4.13 and in nerve root compression were 54.84%, 100%, 57.58%, 100%, 12.5% respectively. The same statistics of full protocol MRI in diagnosis of LDH were 82.61%, 70.80%, 78.79%, 86.36%, 63.64%, 2.75 and of nerve root compression were 80.65%, 100%, 81.82%, 100%, 25% respectively. The sensitivity and specificity in diagnosis of LDH were not different in both protocols but the sensitivity of nerve root compression was statistically significant different (p < 0.013, 95%CI = -0.33, -0.25). CONCLUSION: The authors concluded that limited protocol MRI may replace full protocol MRI in diagnosis of LDH but not in nerve root compression.