Adherence to prescribed explicit criteria during utilization review. An analysis of communications between attending and reviewing physicians
L. C. Kleinman, E. A. Boyd and J. C. Heritage
Department of Pediatrics, University of California, Los Angeles, USA. Kleinman@HSPH.Harvard.edu
CONTEXT: Utilization review (UR) seeks to improve quality and
cost-efficiency of health care. However, how well the process works in
practice has not been assessed. OBJECTIVE: To describe the outcomes of a
sample of physician reviews in terms of the explicit criteria that the UR
was designed to implement. DESIGN: Retrospective analysis of transcripts of
precertification reviews. PARTICIPANTS AND SETTING: California physicians
employed by a UR firm conducted 96 interviews from April 1990 to July 1991
with attending physicians who had proposed to insert tympanostomy tubes on
a patient younger than 16 years and whose proposals had been found to be
inappropriate on an initial screen. MAIN OUTCOME MEASURES: The
appropriateness rating assigned to each case by the physician-reviewer and
by the investigators using explicit criteria. Logistic regression
identified factors associated with the reviewers' recommendations to
perform surgery and with recommendations at variance from the criteria.
RESULTS: The reviewers recommended 78% of cases for surgery, of which only
29% were supported by the criteria or had extenuating circumstances. The
criteria concurred with all 30 of the reviewers' recommendations against
surgery. Two factors, female sex (odds ratio [OR], 8.2; 95% confidence
interval [CI], 1.2-53.8) and previous tympanostomy tube insertion (OR,
30.9; 95% CI, 2.4-394.8) were associated with reviewer recommendations in
favor of surgery that were at variance from the criteria, despite the lack
of evidence for either as a mitigating circumstance. CONCLUSION: Physician
reviewers were more lenient than the explicit criteria that the reviews
were designed to implement. In no cases did the reviewers depart from the
criteria's recommendations in favor of surgery.
