Study objectives: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) ...
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Study objectives: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) adjudicating the claims using a "final diagnosis-based" system. Methods: All outpatient visits from one MCO to an urban, university hospital between January 1, 1998, and February 28, 1999, were included. Each record was reviewed by 2 methods to determine whether the visit qualified for payment under the MCO's benefit structure. Under the provider adjudication, symptom-based system, all visits with nursing triage levels of immediate/emergency were approved automatically. Those with triage levels of delayed/nonurgent were reviewed by an emergency physician and approved if, in the physician's opinion, the presenting symptoms met the emergency criteria under the District of Columbia's Access to Emergency Services Act. A second claims review, blinded to the first, was performed with the diagnosis-based system used by the MCO before approval of the prudent layperson standard. This review divided the records into "approve," "deny," and "suspend" categories according to the discharge International Classification of Diseases, ninth revision code. The results of the 2 reviews were compared. Results: We reviewed 1,830 records;836 (46%) cases were triaged as immediate/emergency and 994 (54%) as delayed/nonurgent. Of the 994 delayed/nonurgent visits, physician review determined that 607 (61%) met the prudent layperson standard and 387 (39%) did not. Overall, the provider self-adjudication system determined that 1,443 (78.8%) of the 1,830 visits should be approved for insurance coverage. The MCO's system approved 966 (53%), denied 335 (18%), and suspended 529 (29%). Provider self-adjudication using a symptom-based system resulted in the immediate approval of 1,443 (77.8%) visits compared with 966 (52.7%) by a diagnosis-based system (P<.001). Excluding the 529 suspended claims, McNemar's
Trauma audit is commonly focused using a Pre-Chart to illustrate calculations made using the TRISS model. A line is drawn at Ps = 0.5 to divide expected survivors and nonsurvivors. The use of this cut-off in a severel...
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Trauma audit is commonly focused using a Pre-Chart to illustrate calculations made using the TRISS model. A line is drawn at Ps = 0.5 to divide expected survivors and nonsurvivors. The use of this cut-off in a severely injured population was examined. The 'M statistic' for a group of injured patients selectively triaged to a Trauma Centre was calculated. The ideal cut-off point between predicted outcomes when using the TRISS model to focus trauma audit in this population was determined using a Receiver Operating Characteristic (ROC) curve. For this population the TRISS 'M statistic' was 0.71 (indicating a significantly different case mix from the reference database) and the best cut-off point was at Ps = 0.76. Trauma audit in populations with a case mix of injury severity different from the reference database should use a different Ps line to define unexpected outcomes. (C) 1999 Elsevier Science Ltd. All rights reserved.
作者：
Angelini, DJBrown Univ
Sch Med Women & Infants Hosp Dept OB GYNNurse Midwifery Sect Providence RI 02912 USA
Obstetric triage services are rapidly advancing, and the concept is becoming a popular practice pattern. As more pregnant women are evaluated in ambulatory settings, especially in high volume obstetric tertiary center...
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Obstetric triage services are rapidly advancing, and the concept is becoming a popular practice pattern. As more pregnant women are evaluated in ambulatory settings, especially in high volume obstetric tertiary centers, it is now realized more and more that labor and other complaints cannot be addressed solely in labor and delivery units, nor are most of these complaints solely labor related. This article presents the results of a national survey designed to discover what contributions nurse-midwives are making to obstetric triage services. In addition, the results provide initial benchmark data on obstetric triage components against which other midwifery services can address practice issues. (C) 1999 by the American College of Nurse-Midwives.
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