Evaluation of a hospital-based utilization management program.

The objective of this study was to evaluate the impact of a utilization management (UM) program designed to decrease inappropriate use of acute care hospital beds while maintaining quality of care. The measure used to define appropriateness was the ISD-A, a diagnosis-independent measurement tool which relies on severity of illness and intensity of service criteria. The outcome measures for the study included appropriate admission to hospital and continued days of stay in hospital, 30-day readmission rates and physician perceptions of the impact of the intervention on quality of care, access to services and patient discharge patterns. The sample frame for the study included two control and two intervention community hospitals, involving 1,800 patient charts. Readmission rates were determined by analyzing all separations from medical services (N = 42,014) in the two experimental and two control hospitals. All physicians with admitting privileges (N = 312) at the intervention hospitals were surveyed; obstetricians, pediatricians, and psychiatrists were excluded from the survey. The results of the study demonstrated that the proportion of inappropriate admissions did not decrease significantly in any of the hospitals, but there were significant decreases in inappropriate continued stay in the intervention hospitals (p < 0.05). Both intervention and one of the control hospitals had lower 30-day readmission rates in the "after" period than in the "before" period (p < 0.05). Eighty-six percent believed that there had been no adverse impact on access to care and, although 25% thought the program may have led to premature discharge, this was not supported by the readmission data.

Utilization management: a literature review for Canadian health care administrators.

Utilization management (UM), the attempt to measure, understand and reduce inappropriate hospital use, has been in development for over 20 years. It is an outgrowth of two related phenomena: (1) the increasing responsibility of large institutional third party payers for health care costs and the increasing demand of those payers for accountability; and (2) in Canada, particularly, the debate surrounding the adequacy of hospital funding and the perceived inadequacy of cost control using global budgeting. Given the interest in UM, hospital administrators, provincial and federal associations representing hospitals, hospital employees and physicians would find a review of UM programs useful in terms of what is known about their effectiveness, and the specific initiatives in Canada. The authors underscore the critical need for formal evaluation of UM programs; to date there has been little systematic research into issues related to its implementation and impact. This issue is particularly pertinent because UM programs have not been widely implemented in Canada.

Hospital-based utilization management: a cross-Canada survey.

Utilization management attempts to measure, understand and, when appropriate, reduce hospital use. We conducted a telephone survey to determine the status of utilization management in Canadian hospitals. The sample comprised a random selection of 30% of acute-care hospitals with over 100 beds for adults in Ontario and Quebec and all such hospitals in the other provinces. Of the 123 chief executive officers contacted 99 (80%) claimed to have a utilization management program. Of those, 90 (91%) agreed to participate in an in-depth survey or to designate a senior administrator to be interviewed who was most knowledgeable about the program. High occupancy rates and funding issues were the most common environmental triggers for the development of utilization management programs; funding issues were listed more frequently by respondents in Ontario than by those elsewhere (p = 0.0008). Retrospective review alone was used in half of the hospitals, concurrent review or some mixed approach being used in the other half. Ontario and the Atlantic provinces were more reliant than the rest of the country on retrospective review alone (p = 0.0032). Most of the hospitals used peer review and education to stimulate corrective action. Of the respondents 67% indicated that the medical staff supported the utilization management program, and 53% reported that the program had a positive impact on the relationship between administrative and medical staff. Most of the respondents were unsure of the program's impact on the quality of care or the rate of unnecessary hospital admission. However, retrospective review alone was found to be less successful in reducing inappropriate utilization than either concurrent review or combined review (p = 0.0048).