Validity of utilization review tools

It is hardly surprising that standard utilization review tools developed for US hospitals are not useful in Canada.1 They have been developed for a different context.

Communities decide how they will deliver care to their constituents. For example, urban communities with a mature home care program will require fewer hospital days than rural communities where it is not cost worthy to provide a full home care program to all who need it.

One way to increase agreement between clinicians and administrators is to support a process in which clinical experts, administrators and communities decide the appropriate setting for various forms of care. Custom-made utilization review tools can then be implemented to test each day whether patients are in the agreed-on and appropriate setting. These systems can also prompt health care providers to move people to the most appropriate setting.

The aim of utilization review is to increase efficiency and value. In this case, a measure of efficiency would be days of care related to change in health. Consequently the most valuable utilization review tools will be able to link health care activities with health care results to help health care providers understand which activities are pertinent to a result and which are superfluous.2