Vydareny K H
Emory University, Atlanta, GA, USA.
Radiol Manage. 1997 Mar-Apr;19(2):40-5.
Performing a clinically unnecessary study can cost a practice money under managed care and capitation contracts. The American College of Radiology (ACR) has developed two tools to help radiology facilities practice cost-efficient medicine without sacrificing quality of care: appropriateness criteria and utilization analysis. Appropriateness criteria were established by the ACR Board of Chancellors in 1993 to help imaging facilities determine appropriate imaging studies; these were first published in 1995; a subsequent edition will be published in 1996 and annually thereafter. Development of the criteria was based on Agency for Health Care Policy and Research guidelines. A task force which clinical conditions and variants were to be studied. The task force then performed a literature search. Members then reviewed the literature and reached a conclusion about the appropriateness of the various procedures. Because capitated contracts require some knowledge of the utilization of services, the ACR formed the utilization analysis committee in 1994. Facilities submit utilization data on a quarterly basis to the ACR. The data is then combined into both regional and national databases. These databases report back to the participating facilities, which can then compare themselves with other groups. All such information is confidential and is used for peer review only. A practice that participates in utilization analysis can view its own contract analysis, particularly in capitated contracts. Since many managed care organizations will not do business with a practice that hasn't performed this type of analysis, utilization analysis can be a way of winning contracts. Utilization analysis can also be a way to identify and control the risks that a practice has with managed care contracts. It offers the means for measuring a practice's performance against regional and national databases, and identifies areas of weakness. A practice is then able to take action to improve its quality of care in those areas.
在管理式医疗和按人头付费合同模式下，开展临床不必要的检查可能会让医疗机构花费资金。美国放射学会（ACR）开发了两种工具，以帮助放射科在不牺牲医疗质量的前提下实现高效成本的医疗实践：适宜性标准和利用情况分析。适宜性标准由ACR理事会于1993年制定，以帮助影像机构确定合适的影像检查；这些标准于1995年首次发布；后续版本将于1996年发布，之后每年发布一次。这些标准的制定基于医疗保健政策与研究机构的指南。一个特别工作组负责确定要研究的临床病症和变量。然后该特别工作组进行文献检索。成员们随后审查文献，并就各种检查程序的适宜性得出结论。由于按人头付费合同需要对服务利用情况有所了解，ACR于1994年成立了利用情况分析委员会。各机构每季度向ACR提交利用情况数据。然后这些数据被整合到区域和国家数据库中。这些数据库会向参与的机构反馈信息，这些机构随后可以将自己与其他机构进行比较。所有此类信息都是保密的，仅用于同行评审。参与利用情况分析的医疗机构可以查看自己的合同分析情况，尤其是在按人头付费合同方面。由于许多管理式医疗组织不会与未进行此类分析的医疗机构开展业务，利用情况分析可以成为赢得合同的一种方式。利用情况分析还可以成为识别和控制医疗机构在管理式医疗合同中面临的风险的一种方式。它提供了根据区域和国家数据库衡量医疗机构绩效的手段，并识别出薄弱环节。然后医疗机构能够采取行动改善这些领域的医疗质量。
