The effect of precertification on the rate of hospitalization of patients with low back pain. A case study comparing hospitalization rates of patients covered by workers' compensation and no-fault automobile insurance in New York State.
This report is a study of the rates of hospitalization of two similar groups of patients with a diagnosis of medical low back pain resulting from an injury. It is based on a 7-year experience with utilization review. None of the patients had met the minimal criteria for hospitalization described by the "Reference Criteria for Short-Stay Hospital Review" of the American Medical Association (1). One of these two groups was required to undergo a preservice review (precertification) before hospitalization. The other group did not undergo this precertification. This study tests the hypotheses that there is a significant incidence of unnecessary hospitalization of patients with medical low back pain and that precertification does reduce this rate of hospitalization. It also tests the hypothesis that race, age, and gender correlate with this unnecessary hospitalization. Further, it examines the relationship between the precertification process and the time of admission and the length of stay once admitted. The methods used are defined, and the controversy surrounding precertification and unnecessary hospitalization in general, and for low back pain in particular, is described.
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D000367:Age Factors; D001416:Back Pain / Q000191:economics* / Q000628:therapy; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007345:Insurance Claim Review; D007346:Insurance, Accident / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D009518:New York; D010343:Patient Admission / Q000706:statistics & numerical data*; D012017:Referral and Consultation; D012737:Sex Factors; D012959:Socioeconomic Factors; D014942:Workers' Compensation / Q000706:statistics & numerical data*