Document Detail

Adherence to prescribed explicit criteria during utilization review. An analysis of communications between attending and reviewing physicians.
MedLine Citation:
PMID:  9256225     Owner:  NLM     Status:  MEDLINE    
CONTEXT: Utilization review (UR) seeks to improve quality and cost-efficiency of health care. However, how well the process works in practice has not been assessed.
OBJECTIVE: To describe the outcomes of a sample of physician reviews in terms of the explicit criteria that the UR was designed to implement.
DESIGN: Retrospective analysis of transcripts of precertification reviews.
PARTICIPANTS AND SETTING: California physicians employed by a UR firm conducted 96 interviews from April 1990 to July 1991 with attending physicians who had proposed to insert tympanostomy tubes on a patient younger than 16 years and whose proposals had been found to be inappropriate on an initial screen.
MAIN OUTCOME MEASURES: The appropriateness rating assigned to each case by the physician-reviewer and by the investigators using explicit criteria. Logistic regression identified factors associated with the reviewers' recommendations to perform surgery and with recommendations at variance from the criteria.
RESULTS: The reviewers recommended 78% of cases for surgery, of which only 29% were supported by the criteria or had extenuating circumstances. The criteria concurred with all 30 of the reviewers' recommendations against surgery. Two factors, female sex (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.2-53.8) and previous tympanostomy tube insertion (OR, 30.9; 95% CI, 2.4-394.8) were associated with reviewer recommendations in favor of surgery that were at variance from the criteria, despite the lack of evidence for either as a mitigating circumstance.
CONCLUSION: Physician reviewers were more lenient than the explicit criteria that the reviews were designed to implement. In no cases did the reviewers depart from the criteria's recommendations in favor of surgery.
L C Kleinman; E A Boyd; J C Heritage
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  JAMA     Volume:  278     ISSN:  0098-7484     ISO Abbreviation:  JAMA     Publication Date:  1997 Aug 
Date Detail:
Created Date:  1997-08-21     Completed Date:  1997-08-21     Revised Date:  2014-09-17    
Medline Journal Info:
Nlm Unique ID:  7501160     Medline TA:  JAMA     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  497-501     Citation Subset:  AIM; IM    
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MeSH Terms
Child, Preschool
Data Collection
Drug Utilization Review / organization & administration*,  standards
Logistic Models
Medical Staff, Hospital / standards*
Middle Ear Ventilation*
Professional Staff Committees* / standards
Quality Control
Retrospective Studies

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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