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Related Experiment Videos

Focused utilization review strategies.

I Strumwasser1, N Paranjpe, D L Ronis

  • 1Michigan Health Care Education and Research Foundation, Detroit 48226.

QRB. Quality Review Bulletin
|August 1, 1989
PubMed
Summary

Focused utilization review (UR) on specific Diagnosis-Related Groups (DRGs) significantly improves efficiency. Targeting DRGs with high nonacute admission rates identifies most nonacute cases and potential cost savings.

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Area of Science:

  • Health Services Research
  • Healthcare Management
  • Quality Improvement

Background:

  • Nonacute inpatient hospital admissions represent a significant area for utilization review (UR) and cost-saving opportunities.
  • Existing UR strategies may not be optimally efficient in identifying these nonacute cases.
  • The Michigan Health Care Education and Research Foundation investigated methods to enhance UR effectiveness.

Purpose of the Study:

  • To compare three focused utilization review strategies for identifying nonacute inpatient hospital admissions.
  • To determine the most effective and efficient method for detecting nonacute cases.
  • To assess the potential for efficiency gains through targeted UR.

Main Methods:

  • Utilized Intensity, Severity, Discharge-Appropriateness (ISD-A) criteria to identify nonacute admissions.

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  • Analyzed 8,973 cases across 73 Michigan hospitals.
  • Compared focused UR strategies, including those using concentration ratios and targeting specific Diagnosis-Related Groups (DRGs).

    • Main Results:

    • Nonacute admissions were prevalent in medical, psychiatric, and substance abuse cases, with lower rates in surgical cases.
    • Strategies employing concentration ratios were most indicative of potential efficiency gains.
    • Focusing UR on DRGs with >15% nonacute rates captured 41% of admissions and accounted for 85% of nonacute admissions, 85% of nonacute days, and 80% of potential dollar savings.

    Conclusions:

    • Targeted utilization review, particularly focusing on DRGs with high nonacute admission rates, is an effective strategy.
    • This focused approach significantly enhances the efficiency and effectiveness of the overall UR process.
    • Healthcare organizations can achieve substantial cost savings by prioritizing UR efforts on high-risk DRGs.