American Journal of Medical Quality

The "anti-dumping" provisions under Section 1867 of the Social Security Act have been clarified and strengthened by recent amendments. Medicare-par ticipating hospitals must post signs informing the public of their obligation to examine, treat, and ap propriately transfer individuals who request emer gency services in the emergency department. Inquir ies about an individual's method of payment or insur ance source may not delay examination or treatment. Qualified personnel must perform medical screening of all emergency patients, and those to be transferred with emergency medical conditions which have not been stabilized must receive treatment to minimize the risk of transfer. There are stepped-up require ments for informed patient consent and documenta tion that the medical benefits of a transfer outweigh the risks. In physician-initiated transfers, the receiv ing hospital must be sent certification by a physician that the benefits of transfer outweigh the risks. Since there is evidence that medically appropriate transfers of persons with emergency medical conditions may actually be underutilized, particularly in rural set tings, medical reviewers should avoid an anti-trans fer bias.

Utilization review (UR) has become a prominent approach to cost containment now used by almost 65% of private group insurance plans. Although insurers have increasingly relied on UR to contain health care costs, until recently little was known about the effects of this cost containment approach. This article re views some of the key findings of a UR evaluation, based on analysis of claims data on 223 insured groups for the years 1984 through 1986. The evalu ation found that UR reduced admissions by 12%, in- patient expenditures by 8%, and total expenditures by 6%. It was estimated that UR generated net sav ings of $115 per employee per year. Groups adopting UR with high baseline rates of hospital use had larger expenditure reductions and greater net savings. It appears that UR can play an important role in private cost containment and help improve medical care re source consumption.

Billing records from the outpatient clinics of a uni versity medical center were used to identify report able communicable diseases. Patient charts were re viewed to check the accuracy of all cases of commu nicable diseases not reported to the local health department. Thirty-three percent of the cases iden tified as one of 20 communicable diseases, using the ICD-9-CM system, were found to be incorrectly coded. This study documents a lack of specificity (nu merous false positives) when using encounter form data and ICD-9-CM codes to identify communicable diseases in an outpatient setting.

In an effort to learn more about resource utilization on ambulatory surgery in hospital departments of surgery and its impact on quality of care, we re viewed the causes of postoperative hospital retention following ambulatory surgery in a hospital-based program. Of 1971 patients operated on in a 6-month period, 188 were retained for a rate of 9.5%. Of these, 71 (3.6%) were retained for observation and 42 (2.1%) for surgery more extensive than planned. The remaining 75 (3.8%) patients represent complications of surgery or anesthesia. The age distribution of pa tients with complications was the same as the group overall with a single mode at about 30 years, while the distribution of patients retained for observation or who were admitted the day of surgery was bimodal with a second peak at about 70 years. All surgical specialties had comparable rates of postoperative re tention, except gynecology which was significantly lower. Many of the patients had multiple procedures or surgery more extensive than planned.

A program of quality assurance for the laboratory is described that addresses both process and outcome validation. It begins by an analyses of the workload processing sequence, i.e., ordering, collecting, trans porting, analyzing specimens, reporting tests results in a timely manner, and reduction of instrument, staff, and system-related errors in the generation of laboratory information. The observable medical staff requirements for effective utilization of the labora tory is the basis for defining outcome measures.