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. 1987 Dec;22(5):709–769.

Identifying and managing inappropriate hospital utilization: a policy synthesis.

S M Payne 1
PMCID: PMC1065471  PMID: 3121538

Abstract

Utilization review, the assessment of the appropriateness and efficiency of hospital care through review of the medical record, and utilization management, deliberate action by payers or hospital administrators to influence providers of hospital services to increase the efficiency and effectiveness with which services are provided, are valuable but relatively unfamiliar strategies for containing hospital costs. The purpose of this synthesis is to increase awareness of the scope of and potential for these approaches among health services managers and administrators, third-party payers, policy analysts, and health services researchers. The synthesis will assist the reader to trace the conceptual context and the historical development of utilization review from unstructured methods using individual physicians' professional judgment to structured methods using explicit criteria; to establish the context of utilization review and clarify its uses; to understand the concepts and tools used in assessing the efficiency of hospital use; and to select, design, and evaluate utilization review and utilization management programs. The extent of inappropriate (medical unnecessary) hospital utilization and the factors associated with it are described. Implications for managers, providers, and third-party payers in targeting utilization review and in designing and evaluating utilization management programs are discussed.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. BUTLER J. J., QUINLAN J. W. Internal audit in the department of medicine of a community hospital; two years' experience. J Am Med Assoc. 1958 May 31;167(5):567–572. doi: 10.1001/jama.1958.02990220037011. [DOI] [PubMed] [Google Scholar]
  2. Berg R. L., Browning F. E., Hill J. G., Wenkert W. Assessing the health care needs of the aged. Health Serv Res. 1970 Spring;5(1):36–59. [PMC free article] [PubMed] [Google Scholar]
  3. Burford R., Averill R. F. The relationship between diagnostic information available at admission and discharge for patients in one PSRO setting: implications for concurrent review. Med Care. 1979 Apr;17(4):369–381. doi: 10.1097/00005650-197904000-00005. [DOI] [PubMed] [Google Scholar]
  4. Demlo L. K. Assuring quality of health care. An overview. Eval Health Prof. 1983 Jun;6(2):161–196. doi: 10.1177/016327878300600204. [DOI] [PubMed] [Google Scholar]
  5. Demlo L. K., Campbell P. M., Brown S. S. Reliability of information abstracted from patients' medical records. Med Care. 1978 Dec;16(12):995–1005. doi: 10.1097/00005650-197812000-00003. [DOI] [PubMed] [Google Scholar]
  6. Donabedian A. Criteria, norms and standards of quality: what do they mean? Am J Public Health. 1981 Apr;71(4):409–412. doi: 10.2105/ajph.71.4.409. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Eddy D. M. Variations in physician practice: the role of uncertainty. Health Aff (Millwood) 1984 Summer;3(2):74–89. doi: 10.1377/hlthaff.3.2.74. [DOI] [PubMed] [Google Scholar]
  8. Fuchs V. R. Has cost containment gone too far? Milbank Q. 1986;64(3):479–488. [PubMed] [Google Scholar]
  9. Gertman P. M., Monheit A. C., Anderson J. J., Eagle J. B., Levenson D. K. Utilization review in the United States: results from a 1976-1977 national survey of hospitals. Med Care. 1979 Aug;17(8 Suppl):i-iii, 1-148. [PubMed] [Google Scholar]
  10. Gertman P. M., Restuccia J. D. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981 Aug;19(8):855–871. [PubMed] [Google Scholar]
  11. Glass R. I., Mulvihill M. N., Smith H., Jr, Peto R., Bucheister D., Stoll B. J. The 4 score: an index for predicting a patient's non-medical hospital days. Am J Public Health. 1977 Aug;67(8):751–755. doi: 10.2105/ajph.67.8.751. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Goldberg G. A., Holloway D. C. Emphasizing "level of care" over "length of stay" in hospital utilization review. Med Care. 1975 Jun;13(6):474–485. doi: 10.1097/00005650-197506000-00004. [DOI] [PubMed] [Google Scholar]
  13. Hornbrook M. C. Hospital case mix: its definition, measurement and use: Part I. The conceptual framework. Med Care Rev. 1982 Spring;39(1):1–43. doi: 10.1177/107755878203900101. [DOI] [PubMed] [Google Scholar]
  14. Iezzoni L. I., Moskowitz M. A. Clinical overlap among medical diagnosis-related groups. JAMA. 1986 Feb 21;255(7):927–929. [PubMed] [Google Scholar]
  15. Inui T. S., Stevenson K. M., Plorde D., Murphy I. Identifying hospital patients who need early discharge planning for special dispositions: a comparison of alternative techniques. Med Care. 1981 Sep;19(9):922–929. doi: 10.1097/00005650-198109000-00004. [DOI] [PubMed] [Google Scholar]
  16. LEMBCKE P. A. Medical auditing by scientific methods; illustrated by major female pelvic surgery. J Am Med Assoc. 1956 Oct 13;162(7):646–655. doi: 10.1001/jama.1956.72970240010009. [DOI] [PubMed] [Google Scholar]
  17. Luft H. S. How do health-maintenance organizations achieve their "savings"? N Engl J Med. 1978 Jun 15;298(24):1336–1343. doi: 10.1056/NEJM197806152982404. [DOI] [PubMed] [Google Scholar]
  18. McClure W. Toward development and application of a qualitative theory of hospital utilization. Inquiry. 1982 Summer;19(2):117–135. [PubMed] [Google Scholar]
  19. McMahon L. F., Jr, Newbold R. Variation in resource use within diagnosis-related groups. The effect of severity of illness and physician practice. Med Care. 1986 May;24(5):388–397. doi: 10.1097/00005650-198605000-00002. [DOI] [PubMed] [Google Scholar]
  20. Mills D. H. Medical insurance feasibility study. A technical summary. West J Med. 1978 Apr;128(4):360–365. [PMC free article] [PubMed] [Google Scholar]
  21. Morehead M. A., Donaldson R. Quality of clinical management of disease in comprehensive neighborhood health centers. Med Care. 1974 Apr;12(4):301–315. doi: 10.1097/00005650-197404000-00002. [DOI] [PubMed] [Google Scholar]
  22. Morehead M. A. The medical audit as an operational tool. Am J Public Health Nations Health. 1967 Sep;57(9):1643–1656. doi: 10.2105/ajph.57.9.1643. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Nobrega F. T., Krishan I., Smoldt R. K., Davis C. S., Abbott J. A., Mohler E. G., McClure W. Hospital use in a fee-for-service system. JAMA. 1982 Feb 12;247(6):806–810. [PubMed] [Google Scholar]
  24. Pettengill J., Vertrees J. Reliability and validity in hospital case-mix measurement. Health Care Financ Rev. 1982 Dec;4(2):101–128. [PMC free article] [PubMed] [Google Scholar]
  25. ROSENFELD L. S. Quality of medical care in hospitals. Am J Public Health Nations Health. 1957 Jul;47(7):856–865. doi: 10.2105/ajph.47.7.856. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Restuccia J. D., Holloway D. C. Barriers to appropriate utilization of an acute facility. Med Care. 1976 Jul;14(7):559–573. doi: 10.1097/00005650-197607000-00002. [DOI] [PubMed] [Google Scholar]
  27. Restuccia J. D., Kreger B. E., Payne S. M., Gertman P. M., Dayno S. J., Lenhart G. M. Factors affecting appropriateness of hospital use in Massachusetts. Health Care Financ Rev. 1986 Fall;8(1):47–54. [PMC free article] [PubMed] [Google Scholar]
  28. Restuccia J. D., Payne S. M., Lenhart G., Constantine H. P., Fulton J. P. Assessing the appropriateness of hospital utilization to improve efficiency and competitive position. Health Care Manage Rev. 1987 Summer;12(3):17–27. doi: 10.1097/00004010-198701230-00006. [DOI] [PubMed] [Google Scholar]
  29. Restuccia J. D. The effect of concurrent feedback in reducing inappropriate hospital utilization. Med Care. 1982 Jan;20(1):46–62. doi: 10.1097/00005650-198201000-00004. [DOI] [PubMed] [Google Scholar]
  30. Richardson F. M. Peer review of medical care. Med Care. 1972 Jan-Feb;10(1):29–39. doi: 10.1097/00005650-197201000-00004. [DOI] [PubMed] [Google Scholar]
  31. Rishpon S., Lubacsh S., Epstein L. M. Reliability of a method of determining the necessity for hospitalization days in Israel. Med Care. 1986 Mar;24(3):279–282. doi: 10.1097/00005650-198603000-00010. [DOI] [PubMed] [Google Scholar]
  32. Rosser R. M. The reliability and application of clinical judgment in evaluating the use of hospital beds. Med Care. 1976 Jan;14(1):39–47. doi: 10.1097/00005650-197601000-00004. [DOI] [PubMed] [Google Scholar]
  33. Rutstein D. D., Berenberg W., Chalmers T. C., Child C. G., 3rd, Fishman A. P., Perrin E. B. Measuring the quality of medical care. A clinical method. N Engl J Med. 1976 Mar 11;294(11):582–588. doi: 10.1056/NEJM197603112941104. [DOI] [PubMed] [Google Scholar]
  34. Sanazaro P. J. Quality assessment and quality assurance in medical care. Annu Rev Public Health. 1980;1:37–68. doi: 10.1146/annurev.pu.01.050180.000345. [DOI] [PubMed] [Google Scholar]
  35. Simborg D. W. DRG creep: a new hospital-acquired disease. N Engl J Med. 1981 Jun 25;304(26):1602–1604. doi: 10.1056/NEJM198106253042611. [DOI] [PubMed] [Google Scholar]
  36. Siu A. L., Sonnenberg F. A., Manning W. G., Goldberg G. A., Bloomfield E. S., Newhouse J. P., Brook R. H. Inappropriate use of hospitals in a randomized trial of health insurance plans. N Engl J Med. 1986 Nov 13;315(20):1259–1266. doi: 10.1056/NEJM198611133152005. [DOI] [PubMed] [Google Scholar]
  37. Steel K., Gertman P. M., Crescenzi C., Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981 Mar 12;304(11):638–642. doi: 10.1056/NEJM198103123041104. [DOI] [PubMed] [Google Scholar]
  38. Steel K. Iatrogenic disease on a medical service. J Am Geriatr Soc. 1984 Jun;32(6):445–449. doi: 10.1111/j.1532-5415.1984.tb02221.x. [DOI] [PubMed] [Google Scholar]
  39. WENKERT W., TERRIS M. Methods and findings in a local chronic illness study. Am J Public Health Nations Health. 1960 Sep;50:1288–1297. doi: 10.2105/ajph.50.9.1288. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Waldo D. R., Levit K. R., Lazenby H. National health expenditures, 1985. Health Care Financ Rev. 1986 Fall;8(1):1–21. [PMC free article] [PubMed] [Google Scholar]
  41. Wennberg J., Gittelsohn A. Variations in medical care among small areas. Sci Am. 1982 Apr;246(4):120–134. doi: 10.1038/scientificamerican0482-120. [DOI] [PubMed] [Google Scholar]
  42. Wilson P., Tedeschi P. Community correlates of hospital use. Health Serv Res. 1984 Aug;19(3):333–355. [PMC free article] [PubMed] [Google Scholar]
  43. Zimmer J. G. Length of stay and hospital bed misutilization. Med Care. 1974 May;12(5):453–462. doi: 10.1097/00005650-197405000-00007. [DOI] [PubMed] [Google Scholar]

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