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Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization's emergency department claim review process

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ANNALS OF EMERGENCY MEDICINE 2000年第3期36卷 212-218页

作者： Shesser, R Holtermann, K Smith, J Braun, J George Washington Univ Dept Emergency Med Washington DC 20037 USA

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

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Realizing the potential of clinical judgment: A real-time strategy for predicting outcomes and cost for medical inpatients

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AMERICAN JOURNAL OF MEDICINE 2000年第3期109卷 189-195页

作者： Charlson, ME Hollenberg, JP Hou, J Cooper, M Pochapin, M Pecker, M Cornell Univ Weill Med Coll Div Gen Internal Med Dept Med New York NY 10021 USA New York Presbyterian Hosp New York NY USA

PURPOSE: We sought to determine whether illness severity and anticipated level of function, as evaluated at the time of admission, were associated with outcomes and costs of care for patients admitted to the medical service. METHODS: hll 1,759 patients admitted to the medical service at a large urban academic medical center between July 1, 1997, and September 30, 1997 (excluding those admitted directly to the intensive care units or for protocol chemotherapy), were evaluated and categorized by the admitting intern by illness severity (not ill, mildly ill, moderately ill, severely ill, or moribund) and anticipated level of function at discharge (excellent, good, fair, or poor) as part of their routine sign-out process. Interns' ratings were always available within 24 to 28 hours of admission. In-hospital mortality, length of stay, cost of hospitalization, and anticipated billing revenue were evaluated. RESULTS: Patients who were more severely ill had significantly greater in-hospital mortality. For example, mortality was 1.1% (11 of 972) among those who were not ill or mildly ill, 3.6% (26 of 724) among those who were moderately ill, and 15% (9 of 60) among those who were severely ill. Illness severity (P = 0.003) and anticipated functional status (P < 0.01) were significant predictors of in-hospital mortality. Illness severity and function were also significant predictors of greater length of stay and greater costs of hospitalization (all P < 0.0001). The 389 patients who were moderately ill with fair or poor anticipated function were associated with the largest cumulative losses (about $330,ODD during the 3-month period), whereas the 798 mildly ill patients with good or excellent function were associated with the largest cumulative profits ($550,000). CONCLUSION: Physicians' estimates of patients' illness severity and anticipated function at the time of discharge, as made by interns using a system designed to help them sign out to their colleagues, predict outcomes

关键词：医学科学研究中心/经济学医学科学研究中心/统计学和数值数据临床工作能力医院费用医院死亡率医院市区/经济学医院市区/统计学和数值数据判断住院时间/统计学和数值数据纽约市比值比 ROC曲线疾病严重程度指数治疗结果利用情况审核/统计学和数值数据成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Outcomes of coronary angioplasty procedures performed in rural hospitals

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AMERICAN JOURNAL OF MEDICINE 2000年第9期108卷 710-713页

作者： Maynard, C Every, NR Chapko, MK Ritchie, JL Univ Washington Div Cardiol Dept Hlth Serv Seattle WA 98195 USA Dept Vet Affairs Hlth Serv Res & Dev Seattle WA USA Dept Vet Affairs Dept Med Seattle WA USA Univ Washington Dept Med Seattle WA USA

PURPOSE: To determine how many rural hospitals in the United States performed coronary angioplasty;to compare patient outcomes in rural and urban hospitals;and to assess whether outcomes were better in rural hospitals in which more procedures were performed. SUBJECTS AND METHODS: In 1996, among patients 65 years of age and older, 201,869 coronary angioplasties were performed in 996 hospitals that were included in the Medicare Provider Analysis and Review files. Geographic location was defined as rural or urban, according to U.S. Census Bureau criteria. Outcome variables were in-hospital death and coronary artery bypass surgery performed during the same admission. Hospital volumes were categorized as low (less than or equal to 100 cases or fewer per year), medium (101 to 200 cases per year), or high (> 200 cases per year). RESULTS: Fifty-one rural hospitals accounted for 4% of all angioplasties performed. After angioplasty, in-hospital mortality was greater in rural hospitals (8.1% versus 6.4%, P = 0.001) among patients with acute myocardial infarction, but was not different for patients without infarction (1.4% versus 1.3%, P = 0.41). Coronary artery bypass surgery rates during the same admission were similar in rural and urban hospitals. In general, in-hospital mortality and same-admission surgery rates wore lower in high-volume centers in both rural and urban areas. CONCLUSION: Although in-hospital mortality after angioplasty for acute myocardial infarction was worse in low- and medium-volume rural centers, overall outcomes in rural and urban hospitals were similar. Am J Med. 2000;108:710-713. (C)2000 by Excerpta Medica, Inc.

关键词：血管成形术经腔经皮冠状动脉/标准血管成形术经腔经皮冠状动脉/利用冠状动脉分流术/利用医院死亡率医院乡村/统计学和数值数据医院市区/统计学和数值数据 Medicare/统计学和数值数据心肌梗死/死亡率心肌梗死/治疗结果评价(卫生保健)/统计学和数值数据治疗结果美国/流行病学老年人老年人 80以上女(雌)性人类男(雄)性

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A prospective study of surgical site infections in a pediatric hospital in Mexico City

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AMERICAN JOURNAL OF INFECTION CONTROL 2003年第5期31卷 302-308页

作者： Porras-Hernández, JD Vilar-Compte, D Cashat-Cruz, M Ordorica-Flores, RM Bracho-Blanchet, E Avila-Figueroa, C Hosp Infantil Mexico Feder Gomez Dept Cirugia Mexico City DF Mexico Inst Nacl Cancerol Dept Infectol Mexico City DF Mexico Hosp Infantil Mexico Feder Gomez Dept Epidemiol Mexico City DF Mexico

Background: Pediatric surgical site infection (SSI) rates in the United States range from 2.5% to 4.4%. There is little data regarding their risk factors among children. We quantified SSI rates and identified risk factors of SSI in a tertiary care pediatric teaching hospital in Mexico City. Methods: All neurosurgical, cardiovascular, and general surgical patients who underwent operation between Aug 1, 1998, and Jan 31, 1999, were followed-up daily during hospitalization. On postoperative day 30, a full review of microbiology reports and medical records was performed. Univariate and multivariate analyses were done to identify risk factors. Results: Four hundred twenty-eight of 530 children completed follow-up. The overall SSI rate was 18.7%. Forty percent of SSI were superficial incisional, 21 % were deep incisional, and 39% were organ/space infections. For clean, clean-contaminated, contaminated, and dirty procedures, SSI infection rates were 12.4 %, 24.4 %, 14.3 %, and 32.4 %, respectively. Open drains (OR = 2.3;95 % CI = 1.34.2;P < .005) and surgery that lasted 90 or more minutes (OR = 2.9;95% CI = 1.6-5.1;P < .001) were associated with infection. Conclusions: Our rates are greater than comparable reported data among children. Duration of surgery and use of open drains were associated with SSI.

关键词：交叉感染/流行病学医院儿科/标准医院儿科/统计学和数值数据医院教学/标准医院教学/统计学和数值数据医院市区/标准医院市区/统计学和数值数据墨西哥/流行病学前瞻性研究哨点监测外科伤口感染/流行病学外科伤口感染/预防和控制儿童学龄前女(雌)性人类婴儿男(雄)性

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Coronary interventions: Keeping score

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AMERICAN JOURNAL OF MEDICINE 2000年第9期108卷 748-750页

作者： Mathew, V Gersh, BJ Mayo Clin & Mayo Fdn Rochester MN 55905 USA

The relation between coronary interventional volume and procedural outcome remains controversial. Although some studies have demonstrated that procedural volume does not correlate with outcome (1,2), most of the available data suggest that there is a modest inverse relation between operator or hospital volume and the risk of periprocedural adverse events (3–5). The inconsistency of the findings in this area may be a result of variations in case mix (simpler versus more complex cases) and referral patterns, rather than procedural techniques or expertise. As a result, the benchmarking of outcomes based on raw data alone may be misleading. Current American College of Cardiology/American Heart Association (ACC/AHA) recommendations call for a minimum of 75 cases per operator per year and 200 cases per hospital per year to maintain proficiency. Such guidelines discourage the existence of low-volume operators at high-volume centers, as well as low-volume centers within reasonable proximity of high-volume centers in urban areas.

关键词：血管成形术经腔经皮冠状动脉/标准血管成形术经腔经皮冠状动脉/利用冠状动脉分流术/利用医院乡村/统计学和数值数据医院市区/统计学和数值数据心肌梗死/外科学心肌梗死/治疗结果评价(卫生保健) 危险因素治疗结果美国人类

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Hospital service areas and medicaid access in Maryland

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Journal of Health and Social Policy 1993年第4期4卷 19-36页

作者： Basu, J. Oak Meadows Building Room 2306 Baltimore MD 21207 6325 Security Boulevard United States

The study defines a service area (rather than a market area) of an individual hospital. Based on patient origin data, algorithms have been developed to select zip codes on the basis of their contributions to a hospital's discharges, and their ability to fulfill a contiguity principle along with a dependence criterion. The service area concept is also used to evaluate the performances of hospitals in terms of the access to care for Medicaid patients. The analysis shows that the hospital's performance in serving Medicaid patients does not significantly depend on its location, nor does it matter whether it is the only hospital in its jurisdiction.

关键词：算法卫生服务范围/统计学和数值数据数据收集卫生服务易得程度/统计学和数值数据卫生服务研究医院计划/统计学和数值数据医院社区/统计学和数值数据医院社区/利用医院乡村/统计学和数值数据医院乡村/利用医院市区/统计学和数值数据医院市区/利用卫生服务使用研究马里兰 Medicaid/统计学和数值数据 Medicaid/利用美国

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The impact of marketing on hospital performance

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Journal of Hospital Marketing 1994年第2期8卷 87-112页

作者： Gruca, Thomas S. Nath, Deepika University of Iowa Iowa IA 52242 672 Phillips Hall United States York University Toronto Canada

This study examines the effect of traditional and innovative marketing factors on the overall financial, operations and market performance of 71 not-for-profit hospitals in a metropolitan area. Traditional marketing factors of location, services offered and pricing did influence the financial performance of system-affiliated and non-system hospitals. They also influenced the operating performance of urban hospitals and the market performance of non-teaching institutions. In contrast, the innovative marketing factors of physician relations, community relations and specialized sales forces had no significant influence on performance differences among the hospitals in the entire sample and sub-samples based on geography, teaching involvement and system affiliation. © 1994 by The Haworth Press, Inc. All rights reserved.

关键词：社区和机构的关系数据收集决策组织财务管理医院/统计学和数值数据医院收费医院医生关系医院市区/经济学医院市区/统计学和数值数据医院慈善/经济学医院慈善/统计学和数值数据卫生服务使用研究/方法卫生服务使用研究/统计学和数值数据组织改革专业场所方案评价回归分析美国

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An approach to improving hospital advertising

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Journal of Hospital Marketing 1996年第1期11.0卷 53-64页

作者： Gombeski W.R., Jr. Luck, C. Camden, C. Pimlott, C. Rucker J.B., Jr. Wilker, M. The Cleveland Clinic Foundation Cleveland OH 44195 9500 Euclid Avenue United States

Newspaper ads from hospitals in Ohio were rated for their effectiveness and explicit use of marketing principles. Analysis showed that the advertising could be improved by increasing the motivation for action, emphasizing how the organization's products and services are different from competitors and more thoroughly identifying the benefits the consumer would receive. Use of the two forms in the study can contribute to improved health care advertising.

关键词：广告(主题)/标准广告(主题)/统计学和数值数据用户满意医院管理/统计学和数值数据医院死亡率医院县/统计学和数值数据医院市区/统计学和数值数据卫生服务使用研究/方法卫生服务使用研究/统计学和数值数据报纸俄亥俄/流行病学方案评价人类

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Has Medicare been a 'bad deal' for rural hospitals?

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The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association 1991年第5期7卷 599-617页

作者： Rizzo, J.A. School of Medicine Yale University New Haven CT 06510.

Understanding the links between Medicare involvement and financial performance in rural hospitals is important for evaluating reimbursement policy under Medicare's prospective payment system (PPS). While simple comparisons between urban and rural hospitals suggest that the latter have lower PPS profit margins on average, there is little multivariate evidence on how Medicare involvement affects financial performance in rural hospitals and whether this relationship differs between rural and urban hospitals. Existing multivariate evidence suggests that Medicare involvement improves PPS profits in both rural and urban hospitals after controlling for other hospital- and market-specific factors. By contrast, the present analysis considers the relationship between Medicare involvement and broader measures of profitability than PPS profits. This provides insight into whether Medicare reimbursement is adequate relative to other forms of third-party payment. The results indicate that Medicare involvement has a markedly different effect on the profitability of rural versus urban hospitals. Greater Medicare involvement is associated with lower patient care profitability in rural hospitals but has a strong positive and significant effect on both patient care and overall (i.e., patient and nonpatient) profitability in urban ones. Medicare involvement is not significantly related to overall profitability in rural hospitals, however, suggesting that these hospitals may be able to mitigate patient care revenue shortfalls from greater Medicare involvement by increasing their nonpatient care revenue sources.

关键词：数据收集财务管理医院/发展趋势卫生服务研究/方法医院乡村/经济学医院市区/经济学医院市区/统计学和数值数据 MedicareA部/经济学 MedicareA部/统计学和数值数据多元分析方案评价预期支付系统/经济学研究设计美国

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Is There a Role for the Small Rural Hospital?

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The Journal of Rural Health 1990年第2期6卷 101-118页

作者： Hart, L. Gary Amundson, Bruce A. Rosenblaff, Roger A. Hart, L. Gary Rosenblatt, Roger A. Department of Family Medicine University of Washington Seattle 98195.

Rural hospitals represent almost half of all short‐stay nonfederal general hospitals in the United States, but have been more severely affected than their urban counterparts by changes in reimbursement, regulation, and technology. Two hundred and six rural community hospitals closed during thefirst nineyears of the 1980s, and the rate of closure is accelerating. Using secondary data sources to examine the structure, role, and content of rural hospitals, small rural hospitals are described and compared to larger and nonrural hospitals. Rural hospitals differ systematically from other hospitals in the United States, with smaller daily censuses, lower occupation rates, shorter lengths of stay, and disproportionately high shares of Medicare patients. They are dominated by very small institutions, with more than 1,000 rural hospitals having fewer than 50 beds. Small rural hospitals offer a core of basic services to the populations they serve. Emergency, obstetric, and newborn services are virtually ubiquitous in rural hospitals of all sizes, and they are also more likely to offer long‐term nursing and home care services than urban hospitals of similar size. The inpatient diagnostic and procedural mix of these institutions demonstrates that they provide care for common medical and surgical conditions of low complexity. Rural hospitals are also relatively inexpensive, representing only 6 percent of total expenditures for hospital care. Given their central role in supporting the provision of health services to rural areas, the apparent appropriateness of the conditions they treat, and their relatively modest cost, it would seem reasonable to use federal policy to stabilize our previous investment in these institutions. Copyright © 1990, Wiley Blackwell. All rights reserved

关键词：数据收集人口统计学评价研究医院病床数 100张以下医院/统计学和数值数据医院乡村/统计学和数值数据医院市区/统计学和数值数据角色外科手术美国人类

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