The impact of utilization management on readmissions among patients with cardiovascular disease.
OBJECTIVE
To determine if prospective utilization reviews that lead to reduced hospital length of stay (LOS) relative to days requested by an attending physician affect the likelihood of readmission for privately insured patients with cardiovascular disease.


METHODS
Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews performed on patients with cardiovascular disease.


METHODS
We used proportional hazard analysis (Cox regression) to investigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and procedural admissions.


RESULTS
There were 2,813 requests for medical admission, and 1,513 requests for procedural admission. Requests for admission were rarely denied. Length of stay was reduced relative to that requested by the treating physician for 17 percent and 19 percent of medical and procedural admissions, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for medical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be readmitted within 60 days as those who had no reduction in their length of stay (95% CI: 1.3-5.1; p < .005).


CONCLUSIONS
Utilization management (UM) rarely denies requests for inpatient treatment of cardiovascular disease. The association between LOS reduction and the likelihood of readmission for patients admitted for cardiovascular procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and quality of care.
Lessler
D S
DS
Dept. of Medicine, Harborview Medical Center and the University of Washington, Seattle 98195-7660, USA.
Wickizer
T M
TM
D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000628:therapy*; D003211:Concurrent Review / Q000592:standards*; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility; D006302:Health Services Research; D006801:Humans; D007345:Insurance Claim Review / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000706:statistics & numerical data*; D016013:Likelihood Functions; D008297:Male; D008329:Managed Care Programs / Q000458:organization & administration; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models