scholarly journals Specialty Pharmaceuticals – Utilization Management

2017 ◽  
Vol 64 (3) ◽  
pp. 15-23
Author(s):  
Craig Stern
Keyword(s):  
Acute Care Hospital ◽  
Major Complication ◽  
Utilization Review ◽  
Care Hospital ◽  
Utilization Management ◽  
Hospital Stays ◽  
Specialty Medication ◽  
The Individual ◽  
New Treatments ◽  
Step Therapy

Specialty medications are complicated, treat complicated diseases, and are costly. Yet, even if their cost was to be decreased by 50%, many of the specialty medications would still be too costly either with high copays, or be unaffordable under any circumstance. Hence the use and oversight of Specialty medications is more complex than just cost: effectiveness, risk and cost must be evaluated concurrently. Utilization is actually the great multiplier. No matter the individual cost of a medication, uncontrolled expansion of medication use leads to more drugs, and therefore, higher drug spend. Utilization management of Specialty medications is, thus, a multifactorial process that is as important as cost management. Human Insulin was the first of the so-called “Specialty Medication.” Specialty treatments followed for orphan and previously untreated diseases. Treatments for chronic diseases followed where Specialty medications replaced older small molecules. The major complication was that the cost of these new treatments rivals, and often exceeds, acute care hospital stays. Unfortunately, evidence has not always matched the comparative benefits of Specialty medications over their small molecule counterparts. As a result, the explosion of new Specialty medications has also stimulated the need for strong evidence that these medications are significant improvements over prior therapies. If so, how can they be affordable? Utilization management of Specialty medications shares many of the same elements that have been used for decades to monitor and manage all treatments; namely, prior authorization, drug utilization review, step therapy, and quantity limits. This paper will examine the approach to utilization management of Specialty medications with the goals of providing a template for providers to participate in this management as well as to understand the metrics applied when these medications are submitted for payment.

A Seat at the Table: Designing an Activity-Based Community Advisory Committee With People Living With HIV Who Use Drugs

2018 ◽  
Vol 29 (7) ◽  
pp. 1029-1042 ◽  
Author(s):  
Sarah Switzer ◽  
Soo Chan Carusone ◽  
Adrian Guta ◽  
Carol Strike
Keyword(s):  
Acute Care Hospital ◽  
Community Based Participatory Research ◽  
People Living With Hiv ◽  
Care Hospital ◽  
Health Issues ◽  
Community Members ◽  
Advisory Committees ◽  
Hospital Stays ◽  
Living With Hiv

Recently, scholars have begun to critically interrogate the way community participation functions discursively within community-based participatory research (CBPR) and raise questions about its function and limits. Community advisory committees (CACs) are often used within CBPR as one way to involve community members in research from design to dissemination. However, CACs may not always be designed in ways that are accessible for communities experiencing the intersections of complex health issues and marginalization. This article draws on our experience designing and facilitating Research Rec’—a flexible, and activity-based CAC for a project about the acute-care hospital stays of people living with HIV who use drugs. Using Research Rec’ as a case study, we reflect on ethical, methodological, and pedagogical considerations for designing and facilitating CACs for this community. We discuss how to critically reflect on the design and facilitation of advisory committees, and community engagement processes in CBPR more broadly.

Evaluation of a Hospital-Based Utilization Management Program

1995 ◽  
Vol 8 (1) ◽  
pp. 38-45 ◽  
Author(s):  
Karen Cardiff ◽  
Geoffrey Anderson ◽  
Samuel Sheps
Keyword(s):  
Quality Of Care ◽  
Acute Care Hospital ◽  
Severity Of Illness ◽  
Management Program ◽  
Measurement Tool ◽  
Care Hospital ◽  
Readmission Rates ◽  
Utilization Management ◽  
The Impact

The objective of this study was to evaluate the impact of a utilization management (UM) program designed to decrease inappropriate use of acute care hospital beds while maintaining quality of care. The measure used to define appropriateness was the ISD-A, a diagnosis-independent measurement tool which relies on severity of illness and intensity of service criteria. The outcome measures for the study included appropriate admission to hospital and continued days of stay in hospital, 30-day readmission rates and physician perceptions of the impact of the intervention on quality of care, access to services and patient discharge patterns. The sample frame for the study included two control and two intervention community hospitals, involving 1,800 patient charts. Readmission rates were determined by analyzing all separations from medical services (N=42,014) in the two experimental and two control hospitals. All physicians with admitting privileges (N=312) at the intervention hospitals were surveyed; obstetricians, pediatricians, and psychiatrists were excluded from the survey. The results of the study demonstrated that the proportion of inappropriate admissions did not decrease significantly in any of the hospitals, but there were significant decreases in inappropriate continued stay in the intervention hospitals (p < 0.05). Both intervention and one of the control hospitals had lower 30-day readmission rates in the “after” period than in the “before” period (p < 0.05). Eighty-six percent believed that there had been no adverse impact on access to care and, although 25% thought the program may have led to premature discharge, this was not supported by the readmission data.

Hospital utilization, efficiency and access to care during and shortly after restructuring acute care in Newfoundland and Labrador

2005 ◽  
Vol 10 (2_suppl) ◽  
pp. 31-37 ◽  
Author(s):  
Brendan Barrett ◽  
Christine Way ◽  
Jackie McDonald ◽  
Patrick Parfrey
Keyword(s):  
Acute Care ◽  
Newfoundland And Labrador ◽  
Average Length ◽  
Acute Care Hospital ◽  
Utilization Efficiency ◽  
Utilization Review ◽  
Care Hospital ◽  
Surgical Data ◽  
The Impact ◽  
Over Time

Objectives Since the 1990s restructuring, including regionalization and downsizing, has largely been driven by a desire for cost containment. Regionalization, hospital closure and changes in management processes occurred in Newfoundland and Labrador (NL), Canada between 1995 and 2000. The objectives of the current study were: to describe trends in the utilization of acute care hospital services by residents of NL during and shortly after restructuring; to examine trends in the efficiency of utilization of acute care beds in the province during the same time frame; and to compare the trends in St John's with the rest of the province, taking account of confounding events, in an attempt to understand the impact of aggregation of hospitals in this region. Methods Hospital discharge and day surgical data were analysed for all facilities in NL from 1995/96 to 2000/01. Analyses were by facility of service and also by region of residence directly standardized to the provincial population for 1996. Efficiency of bed utilization was examined on three occasions by concurrent utilization review using a modified version of the Appropriateness Evaluation Protocol. Trends in the St John's region (where most tertiary services are located and greater aggregation of hospitals occurred) were compared with the rest of the province. Results Admissions declined by 14% in St John's facilities and by 17% elsewhere. Inpatient days fell by 9% in St John's and by 12% elsewhere. Average length of stay and Resource Intensity Weight changed little, apart from a rise in the final study year, with the largest change in St John's. Standardized hospital admission rates declined by 10% and inpatient days by 5.6% for residents of St John's region, and by 16% and 14% respectively for residents of other regions. There was no change over time in the use of day surgery. Efficiency of acute care bed use improved in 2002 in St John's, but was unchanged in other regions. Use of acute care beds by elderly patients for extended stay, or when an alternate level of care would have been appropriate, was greater in St John's with the disparity persisting over time. Waiting time for continuing care in the StJohn's region was unchanged comparing 1995/96 and 1999/00. Conclusions Regionalization in Newfoundland and Labrador facilitated aggregation of hospitals, but did not control the number of front-line workers and, consequently, total acute care expenditure. Expenditure increased significantly between1995 and 2002, at a rate which exceeded the increase in government revenues. The government's ability to pay for acute care will not be achieved unless employee costs are controlled or provincial income increases.

scholarly journals 113. Understanding the Changes in Infective Endocarditis Admission in Pennsylvania During the Opioid Crisis

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S88-S88
Author(s):  
Jessica A Meisner ◽  
Judith A Anesi ◽  
Judith A Anesi ◽  
Xinwei Chen ◽  
Dave Grande
Keyword(s):  
Infective Endocarditis ◽  
Health Care Cost ◽  
Acute Care Hospital ◽  
Hospital Charges ◽  
Care Hospital ◽  
Opioid Crisis ◽  
Care Models ◽  
Hiv Serostatus ◽  
The Face ◽  
Hospital Stays

Abstract Background Nationwide, there has been a rise in cases of infective endocarditis (IE) correlating with the rise of the opioid crisis. Pennsylvania (PA) has the third highest rate of drug overdose deaths in the country, with Allegheny and Philadelphia counties having the highest rates in the country. With this study, we evaluated how IE has changed in the face of the opioid crisis with respect to the population impacted and associated healthcare utilization in PA. Methods We performed a retrospective cohort study of all adults admitted to an acute care hospital in PA between January 2013 and March 2017 with a diagnosis of IE. Patients were identified through the Pennsylvania Health Care Cost Containment Council (PHC4) via billing codes. Exposed patients were those with drug use-associated IE (DU-IE); the unexposed group was those with non-DU-IE. We determined the number of admissions and geographical distribution of IE and DU-IE in the state. We then assessed for differences in hepatitis C (HCV) and HIV serostatus, length of stay (LOS), insurance status, total hospital charges, and rates of valve surgery between the two groups. Results There were 17,224 admissions for IE in PA during the study period, of which 11.2% were DU-IE. In Allegheny and Philadelphia counties, 14.4% and 20.5% were from DU-IE, respectively. DU-IE cases increased from 6% in 2013 to 17% in 2017, P < 0.001. We found several significant differences between the DU-IE and non-DU-IE groups: DU-IE group was younger (median 33 vs. 69 years old, P < 0.001); the LOS was longer in the DU-IE group (10 vs. 7 days, P < 0.001); the percentage of patients leaving Against Medical Advice was higher in DU-IE group (15.7% vs. to 1.1%, P < 0.001); a higher proportion of the DU-IE group were HCV and HIV seropositive (27.1% vs. 3.3% for HCV, 2.4% vs. 0.74% for HIV, P < 0.001). See figures for complete results. Conclusion Pennsylvania had an increase in the number of IE cases over the last 4 years, driven by the opioid crisis, with Philadelphia and Alleghany counties being the most impacted areas. While this study is limited by the use of claims data, it demonstrates the downstream effects of the opioid crisis on the patient population at risk and the healthcare system due to longer and costlier hospital stays. This study supports the need for innovative and integrative care models to support them. Disclosures All authors: No reported disclosures.

Comparative Evaluation of Malnutrition Screening in Oncology Patients in an Acute Care Hospital: A Pilot Study

2017 ◽  
Vol 1 (1) ◽  
Author(s):  
Sinha Chandni Sen ◽  
LaSalle Colette ◽  
Argabright Debra ◽  
Hollenbeck Clarie B
Keyword(s):  
Pilot Study ◽  
Acute Care ◽  
Comparative Evaluation ◽  
Acute Care Hospital ◽  
Care Hospital ◽  
Oncology Patients

A Taxonomy for Psycho-Oncological Intervention Techniques in an Acute Care Hospital in Germany

2021 ◽  
pp. 1-7
Author(s):  
Martina Madl ◽  
Marietta Lieb ◽  
Katharina Schieber ◽  
Tobias Hepp ◽  
Yesim Erim
Keyword(s):  
Acute Care ◽  
Interrater Reliability ◽  
Acute Care Hospital ◽  
Future Research ◽  
Systematic Research ◽  
Care Hospital ◽  
Certification System ◽  
Stepwise Procedure ◽  
Further Development

<b><i>Background:</i></b> Due to the establishment of a nationwide certification system for cancer centers in Germany, the availability of psycho-oncological services for cancer patients has increased substantially. However, little is known about the specific intervention techniques that are applied during sessions in an acute care hospital, since a standardized taxonomy is lacking. With this study, we aimed at the investigation of psycho-oncological intervention techniques and the development of a comprehensive and structured taxonomy thereof. <b><i>Methods:</i></b> In a stepwise procedure, a team of psycho-oncologists generated a data pool of interventions and definitions that were tested in clinical practice during a pilot phase. After an adaptation of intervention techniques, interrater reliability (IRR) was attained by rating 10 previously recorded psycho-oncological sessions. A classification of interventions into superordinate categories was performed, supported by cluster analysis. <b><i>Results:</i></b> Between April and June 2017, 980 psycho-oncological sessions took place. The experts agreed on a total number of 22 intervention techniques. An IRR of 89% for 2 independent psycho-oncological raters was reached. The 22 techniques were classified into 5 superordinate categories. <b><i>Discussion/Conclusion:</i></b> We developed a comprehensive and structured taxonomy of psycho-oncological intervention techniques in an acute care hospital that provides a standardized basis for systematic research and applied care. We expect our work to be continuously subjected to further development: future research should evaluate and expand our taxonomy to other contexts and care settings.

scholarly journals How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

2021 ◽  
pp. 0272989X2199234
Author(s):  
Paul K. J. Han ◽  
Tania D. Strout ◽  
Caitlin Gutheil ◽  
Carl Germann ◽  
Brian King ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Qualitative Study ◽  
Management Strategies ◽  
Acute Care Hospital ◽  
Uncertainty Management ◽  
Care Hospital ◽  
Convenience Sample ◽  
Medical Specialties ◽  
Tolerance Of Uncertainty ◽  
Medical Uncertainty

Background Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. Objectives To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians’ tolerance of medical uncertainty. Design Qualitative study using individual in-depth interviews. Participants Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1–3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine–pediatrics), at a single large US teaching hospital. Measurements Semistructured interviews explored participants’ strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. Results Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. Conclusions Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.

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