Reports from the field-Utilization Review
Reports from the field-Utilization Review
Readmissions don't mean bad care for Medicare patients
A recent study of Medicare patients in four states found that patient readmissions are not necessarily related to poor quality care during the first visit.
Researchers reviewed hospital records on readmission diagnoses and intervening time periods to identify readmissions that indicated potentially inadequate care during initial hospitalization. The study group consisted of 1,758 Medicare patients hospitalized in New York, Pennsylvania, Massachusetts, and Illinois during 1991 and 1992 with pneumonia or congestive heart failure. In simulations, readmission did not vary significantly between average and low quality hospitals.
[See: Weissman JS, Ayanian JZ, Chasen-Taber S, et al. Hospital readmission and quality of care. Medical Care 1999; 37:490-501.]
Studies show many lab tests are conducted unnecessarily
Two recently released studies indicate that some costly lab tests performed in the hospital setting may be unnecessary.
In the first study, researchers found that 84% of inpatient digoxin level tests had no appropriate indication. Of those 84%:
• 76% were serial tests drawn less than 10 days apart;
• 9.5% were performed on patients not receiving digoxin;
• 8.5% were done after initiation of digoxin therapy but before a pharmacological steady state had been achieved;
• 3% were done to follow levels in the toxic range that were measured before the level could be expected to decrease to the therapeutic range.
In addition, 48% of the digoxin levels measured in outpatients had no appropriate indication. Of the inappropriate outpatients digoxin levels:
• 76% were due to early routine monitoring;
• 13 were performed on high-risk patients;
• 2% were performed on patients who had worsening congestive heart failure or atrial fibrillation;
• 2% were performed after changing the digoxin regimen but before a steady state had been reached;
• 8% were due to other causes.
The second study found that a total of 939 apparently redundant tests were ordered over a four-month period at one hospital. Physicians of the 5,700 patients in the study who ordered tests via computer terminal received computerized reminders if a test was redundant, meaning it had been performed previously or was pending. Physicians of the 5,886 patients in the control group received no computerized reminders.
Researchers found that 69% of tests were canceled by study group physicians when a remind -er was sent out. Physicians ordered tests despite computerized reminders in 137 instances. Of those 137, 41% appeared to be justified based on review of patient charts.
[See: Casas F, Tanasijevic MJ, Ma'luf N, et al. Evaluating the appropriateness of digoxin level monitoring. Arch Intern Med 1999; 1,159:363-368. See also: Bates DW, Kuperman GJ, Rittenberg E, et al. A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests. Am J Med 1999; 106:144-150.]
Use of hospitalists has pros and cons
The use of hospitalists is expanding across the country as a new model for inpatient care. A recent supplement in the Annals of Internal Medi cine profiled this growing movement in a recent 10-article supplement. Among listed advantages to the use of hospitalists over primary care physicians are:
• increased availability to hospitalized patients;
• greater hospital experience and expertise;
• increased commitment to hospital quality improvement.
Potential disadvantages for the use of hospitalists rather than primary care physicians are:
• loss of information caused by the outpatient-hospital discontinuity;
• dissatisfaction of patients who are handed off to a new physician at the time of hospital admission.
The supplement includes the first national survey of hospitalists. The survey found that 89% of hospitalists are internists, with 51% being general internists and 38% medical specialists.
The survey also found:
• Most hospitalists limit their practice to the inpatient environment, but 37% continue a limited outpatient primary or consultative practice.
• About one-third (35%) of hospitalists are employed by a medical group, compared with 23% employed by a hospital and 14% by a managed care organization.
• Most hospitalists report job satisfaction, with 84% of generalists and 73% of specialists expecting to still be a hospitalist in three years.
[See: The hospitalist movement in the United States. Ann Intern Med 1999; 130(4):Suppl.]
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