Utilization review: can it be improved?

For many years after the introduction of universal health insurance physicians in Canada enjoyed a relatively high level of professional autonomy. They admitted patients to hospitals, ordered diagnostic tests and therapies and then discharged patients based on their clinical judgement with little supervision or “second-guessing” by government or other third-party payers. The “appropriateness” of their clinical decisions and their use of hospital resources were rarely challenged. However, the recent fiscal crisis surrounding health care in Canada has changed all that. In an environment where hospital budgets are under enormous strain, hospital administrators are trying to increase the appropriate use of hospital beds and reduce the inappropriate use that occurs because of unnecessary admissions and prolonged lengths of stay. Many physicians have found themselves the subject of practice profiling, where their patients’ lengths of stay because of various conditions are compared with those of their peers using data routinely collected in hospital administrative databases. Questions have been raised about why some clinicians appear to have a much lower threshold for admitting patients than others and why lengths of stay vary widely for patients with apparently similar medical conditions. The recognition of widespread practice variation has led to a whole industry devoted to “utilization review.” Developed by the American health insurance industry, utilization review comes in many forms. One form involves the application of objective criteria to determine the appropriateness of hospital admission. A series of explicit, written criteria define when patients with a given condition should be admitted, whether each day in hospital is necessary and when patients should be ready for discharge or for transfer to another level of care. These criteria are applied to data abstracted from the medical record to determine whether both hospital admission and each subsequent day in hospital are “appropriate” or “inappropriate” at a specific level of care. Although these instruments were developed in the United States, they are increasingly being used in Canada and other countries to inform policy decisions regarding the utilization of hospital resources.