Validity of utilization review tools
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* Charles J. Wright
* Karen Cardiff

The conclusion reached by Norman Kalant and colleagues that utilization review tools “have only a low level of validity when compared with a panel of experts, which raises serious doubts about their usefulness for utilization review”1 is not well supported by the data in this very limited study involving 75 patients in a single diagnostic group.

The authors have not recognized that these tools are valuable for system planning as pointers to potential alternative levels of care. In utilization management they are guidelines, not rules. It would be foolish even to consider using such tools exclusively in the decision-making process about clinical management. In our studies we have repeatedly emphasized that the responsible clinician must at all times make the final judgement,2,3 but these guidelines do help to stimulate regular review of the need for hospitalization in the interests of quality care and efficiency. The rate of inappropriate hospitalization may be debated, but it would be difficult to deny that a significant problem exists that can only be addressed by better system planning.

The ISD (Intensity of service, Severity of illness, Discharge screens) guidelines are developed and regularly revised by a more extensive panel process than that used by the authors but they do not take into account whether the more appropriate level of care (for example, outpatient diagnostics or home intravenous therapy) is actually available in the local community. Physicians become justifiably upset if a label of “inappropriate” is applied in the absence of this assessment when the alternatives simply do not exist, but planners need help in creating them.

There is, of course, no perfect tool for assessing the appropriateness of clinical services, but it would be extremely unfortunate if the unjustifiable conclusion of this paper discouraged the use of utilization review tools within the proper context.

## References

1.  1. Kalant N, Berlinguet M, Diodati JG, Dragatakis L, Marcotte F. How valid are utilization review tools in assessing appropriate use of acute care beds? CMAJ 2000;162(13):1809-13.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTYyLzEzLzE4MDkiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTYzLzEwLzEyMzUuNC5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. Wright CJ, Cardiff K, Kilshaw M. Acute medical beds: How are they used in British Columbia? Vancouver: Centre for Health Services and Policy Research, University of British Columbia; 1997. Report no HPRU 97:7D.
    
    

3.  3. Wright CJ, Cardiff K. The utilization of acute care medical beds in Prince Edward Island. Vancouver: Centre for Health Services and Policy Research, University of British Columbia; 1998. Report no HPRU 98:14D.