The Impact of Utilization Management Determination on Hospital Readmission Rates Among Cardiovascular Disease Patients: A Comparison of Appropriate and Inappropriate Utilization Management Decisions

Significance

Patients with cardiovascular disease frequently readmit to the hospital, which raises healthcare expenditures and negatively affects patient outcomes. According to Warchol et al. (2019), effective usage management can lower avoidable readmissions and enhance patient care. In order to examine the effects of good versus wrong utilization management decisions on readmission rates, the study compares the factors that influence hospital readmissions in patients with cardiovascular disease. With the triple purpose of lowering per capita healthcare expenditures, enhancing population health, and enhancing the quality of care, this information can guide quality improvement programs focused on lowering readmission rates and increasing patient outcomes (Warchol et al., 2019). Patients, healthcare professionals, decision-makers, and society would benefit significantly from the study’s potential to reduce healthcare costs while improving cardiovascular disease patient care outcomes and treatment quality.

PICOT Question

Compared to appropriate utilization management decisions in patients diagnosed with cardiovascular disease, how does inappropriate utilization management determination influence the hospital readmission rate six months after discharge?

Search Strategy

A systematic electronic search of numerous databases should be done to perform a thorough search for pertinent studies on the effect of improper versus adequate hospital readmission rates for patients with cardiovascular disease and utilization management. Systematic Reviews, PubMed, Scopus, CINAHL, and Joanne Briggs are a few of these databases. Truncation and Boolean operators should be employed along with search phrases like Cardiovascular illness, ineffective versus effective utilization management, readmissions to the hospital, and discharge planning can be used to extend or narrow the search as necessary (Friedman & Basu, 2004). The search should not include any scholarly or other papers published in English after 2015. An initial review of the selected studies to identify studies that fail to meet the study question should be done as the first step in reviewing the chosen studies. The remaining publications should be evaluated critically using the Johns Hopkins Evidence Level and Quality Guide (Dang et al., 2021). The best articles should be picked after a more thorough review and analysis. Using the search method described above, researchers can find pertinent papers that provide evidence-based details on how UM affects patients with cardiovascular disease hospital readmission rates. This information can inform quality improvement activities and enhance patient outcomes.

Appraisal of Evidence

A Retrospective Cohort Study on appropriate and inappropriate UM decisions was carried out by Riverin et al. (2018). The study comprised 620,656 patients admitted to a community hospital in Quebec, Canada and diagnosed with cardiovascular disease. The study’s objectives were to determine the elements that affect hospital readmissions in people with cardiovascular disease and to contrast the effects of acceptable and unsuitable utilization management choices on readmission rates.

The authors examined the association between suitable and inappropriate utilization management decisions and hospital readmission rates using logistic regression analysis. According to the study’s findings (OR=0.56, p=0.017), proper utilization management decisions were linked to reduced readmission rates than unsuitable ones. The study also discovered many characteristics, such as age, multiple medical conditions, length of stay, and type of cardiovascular illness, that are linked to hospital readmissions.

The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) grading accords the evidence a level IIB rating. Its main advantages are the study’s large sample size and suitable statistical analysis to look at the relationship between utilization management choices and readmission rates. The validity of the results could be hampered by the study’s retrospective nature and dependency on administrative data. Furthermore, the study could have been more extensive in its ability to generalize because it was only carried out at one community hospital. According to the data in this study, making the right utilization management choices may help patients with cardiovascular disease experience fewer hospital readmissions. Additional study is required to confirm these results and evaluate whether the study’s conclusions can be applied to other contexts.

The second evidence is a quantitative retrospective cohort study examining the impact of proper and wrong utilization management strategies on readmission rates among cardiovascular disease patients. The study involved 39,117 patients discharged from a sizable academic medical centre in the United States with a principal diagnosis of cardiovascular disease. The usage management decisions were made by a committee of physician reviewers who assessed the medical significance and suitability of the treatments provided to the patients. (Lessler & Wickizer, 2000). According to the study, individuals with utilization management decisions declared improper experienced a greater readmission rate (39% vs. 16.4%). According to the study, individuals with cardiovascular disease can experience considerably better patient outcomes and readmission rates when appropriate utilization management decisions are made.

The evidence is classified as level II by the JHNEBP. The study has limitations, such as its retrospective design, making it difficult to prove causality. Additionally, because only one medical centre’s patients are included in the study, generalizability to other settings may be constrained. Additionally, a group of physician reviewers involved in the utilization management decisions could have been biased or subjective in their judgments. However, the study offers important information about the potential advantages of sensible utilization management choices in lowering readmission rates and enhancing patient outcomes in people with cardiovascular disease. The study’s conclusions are essential for healthcare professionals, decision-makers, and society because they can guide initiatives to lower healthcare costs and raise the standard of treatment.

The third supporting data is the cohort research by Dupre et al. (2018) titled “Access to routine care and risks for 30-day readmission in patients with cardiovascular disease.” The study included one thousand two hundred thirty-four patients with cardiovascular disease who were hospitalized at a hospital in the United States. The study examined the correlation between readmission rates for cardiovascular disease patients within 30 days and access to routine care. The link between the factors of routine care access and rates of readmission within 30 days was examined by the authors using logistic regression analysis. According to the study, patients who had access to regular care had a higher likelihood of being readmitted within 30 days of their last readmission than patients who did not (OR=1.79, p=0.035). The study also identified many variables, such as age, comorbidities, and duration of stay, that are connected to 30-day readmissions. The JHNEBP evaluation assigns the evidence a level IIB. The study’s suitable statistical analysis and identification of a risk factor modifiable for thirty-day readmission are among its advantages. However, the study’s single-centre methodology and limited sample size might restrict how broadly the results can be applied.

According to the data in this study, routine care access may be crucial in lowering readmission rates within thirty days for patients with cardiovascular disease. To improve patient outcomes, healthcare practitioners should place a high priority on assuring access to regular care. To confirm the results and investigate additional variables that might affect readmission rates in this cohort, more research is required in 2018 (Dupre et al.).

Description of the Framework

The reason for rising healthcare expenses each year is needless hospital readmissions. Practitioners will face intense pressure to cut expenses and eliminate unnecessary re-hospitalizations as the healthcare reform period progresses. Providers should allow patients to return when they require inpatient treatment for medical or surgical issues. However, a significant number of unintentional readmissions may and will be decreased by implementing initiatives that enhance the standard and promote patients as they move through the care continuum (Geri et al., 2020). Hospital utilization management refers to the actions taken by a hospital to guarantee that the care provided is necessary and suitable. Hospital usage management systems will be increasingly important as businesses adopt value-based reimbursement models. Implementing an efficient utilization management program ensures that hospitals offer cost-effective, high-quality care. There is a need for a good utilization management program that has well-defined regulations, processes, and people responsibilities.

The Diffusion of Innovations theory describes how a novel good, thought, or beneficial health practice spreads within a society or social group. Rogers proposed five processes for successful and enduring innovation: awareness, interest, appraisal, trial, and acceptance (Huang et al., 2021). Awareness happens when an unbalanced situation makes the need for change obvious. During the three phases of interest, assessment, and trial, hospital leadership collects data, engages staff, develops a clear strategy, and conducts appropriate testing. Beneficial and practical inventions finally integrate into daily life during the adoption phase. This model highlights the inherent uncertainty in forming new habits and helps public health program implementers decide how to deal with these uncertainties.

Doctors might need to be made aware of medical necessity standards when delivering care. Case managers might only have access to some contractual providers’ policies, which would be necessary to decide on medical necessity in the best way. In addition to doctors, nurses and case managers are crucial components of usage management programs (Kidanemariam et al., 2020). In hospitals, nurses are typically responsible for reviewing utilization because they help patients navigate the healthcare system in a way that provides high-quality, cost-effective treatment. Care coordinators and managers significantly control utilization (Kidanemariam et al., 2020).

Often, nurses need more supervision and administrative support to modify practice. Significant hurdles to nurses’ exploitation of research in practice and the spread of innovation include a lack of fundamental research knowledge, unintelligible data, and inadequate time on the job to execute change. Furthermore, most staff nurses need to be made aware of global advancements. These impediments result in the overuse of ineffective treatment, the underuse of effective care, and execution mistakes. These mistakes result in an increase in patient readmissions to hospitals. The spread of innovation in the healthcare sector could be more active. There is a need to design specific ways to kick-start the innovation-diffusion process.

Understanding and resolving barriers to dissemination for healthcare professionals and patients is critical. Healthcare innovations need many acceptance levels, such as those of head nurses, clinical chiefs, patients, and relatives. A formative review of the complete supply chain that must cooperate for an innovation’s dissemination, delivery, supply, and backing can remove hurdles before launch (Meri et al., 2019). This review involves paying attention to projected intrinsic and monetary incentives, which may be modified to meet different types of stakeholders when formative evaluation indicates that adoption obstacles are substantial, contributing to a climate of change.

Hospital utilization management methods are critical for aiding physicians to deliver cost-effective, high-quality care, decreasing healthcare costs and hospital readmissions. Improvements in the five domains of Rogers’ diffusion of innovations model can result in higher-value care experiences (Meri et al., 2019). Because of diffusion’s bidirectional nature, changes in care delivery are required to produce a genuinely high-value system. Beyond minimizing utilization, value improvement includes performance enhancement across five care delivery pillars. Hospitals may improve diagnostic and treatment efficiency and effectiveness by guiding the optimal use of resources such as lab and imaging tests, procedures, treatments, and drugs. In outpatient and inpatient settings, value improvement assures care delivery consistency to reduce unjustified variability in practice that raises costs without improving results (Bricard & Or, 2019). Quality-driven care pathways shorten hospital stays, reduce infections, minimize readmissions, and enhance outcomes.

Value enhancement enhances care transitions, particularly discharge transitions, to prevent unnecessary postdischarge emergency room visits and hospital readmissions. Value enhancement improves access to preventive medicine and evidence-based screening tests to safeguard patients from avoidable illnesses, hospital-acquired ailments, and late-stage cancer diagnoses (Alhasan et al., 2022). It also optimizes the patient care environment to improve access and efficacy of healthcare in the outpatient setting while reducing unnecessary hospital and ED visits. Patient enlightenment and empowerment are critical components of these initiatives.

Implications for Practice

Based on the information provided, healthcare professionals should give proper utilization management decisions top priority in order to lower hospital readmissions and enhance patient outcomes for people with cardiovascular disease. This can be achieved by putting in place utilization management programs that have physician reviewers assess the medical need and suitability of patient treatments. These programs can additionally involve patient education, care coordination, and planning for discharge to guarantee that patients receive the proper care and follow-up after discharge. Policymakers can also use these findings to support appropriate usage management decisions and lower healthcare costs related to hospital readmissions (Friedman & Basu, 2004). For instance, legislators might create reimbursement models that reward healthcare providers for prioritizing wise utilization management choices and cutting back on needless healthcare use.

The findings of these retrospective cohort studies need to be confirmed by additional research to determine whether the findings are generalizable to other contexts. Future research could investigate how effective utilization management choices affect patient outcomes and decrease hospital readmissions (Harrison et al., 2011). Qualitative research can also identify implementation and sustainability issues by examining patients’ and healthcare professionals’ perceptions of usage management initiatives.

Summary and Synthesis of the Evidence

According to the three pieces of data in this synthesis, wise utilization management choices can considerably lower readmission rates and enhance patient outcomes in cardiovascular disease patients. According to the first Canadian study (Harrison et al., 2011), appropriate usage management decisions were linked to reduced readmission rates than improper utilization management decisions. Age, multiple disorders, length of stay, and type of cardiovascular disease were all characteristics linked in the study to hospital readmissions. The results of the second American study showed that patients with poor utilization management decisions had a considerably higher readmission rate than those with good decisions.

Due to their retrospective designs and the possibility of bias or subjectivity in the evaluations of utilization management decisions, both studies had drawbacks. However, the studies offer essential information about the potential advantages of sensible utilization management choices in lowering readmission rates and enhancing patient outcomes in people with cardiovascular disease. These findings have implications for society, governments, and healthcare providers since they can help guide initiatives to raise the standard of treatment and lower costs. Confirming these results and determining whether they apply to other circumstances will require more investigation.

Conclusion

Nurses have many challenges when adopting changes in clinical practice due to the slow diffusion of information nurse researchers create. However, the diffusion literature offers valuable suggestions for fostering and disseminating change within the healthcare setting. The diffusion of innovations model by Rogers offers methods and ideas that make organizational and individual responsiveness to medical standards and practices more understandable. The adoption of medical innovations can be accelerated and expanded via diffusion ideology. The most vital source of energy and incentive for bringing innovation in healthcare practices to improve health outcomes is the spirit and motivation of the nurses. Health care needs leaders who understand innovation and how it spreads, who value variety in change, and who, using the most outstanding social science as a guide, can nurture innovation in all its rich and varied guises to create a future that varies from the past.

References

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Appendix A: Evaluation Table