UM Focus

URs may not adhere to criteria, study finds

Lenience seen as sandbagging precert

How well does utilization review (UR) actually work in practice? A study from the University of California in Los Angeles looked at 96 reviews that assessed the validity of proposals by attending physicians to insert tympanostomy tubes in young patients.1 The proposals had been found to be inappropriate on initial screens. Although 29% of the proposals were supported by explicit criteria, the reviewers recommended 78% of the cases for surgery. In other words, the 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.

The UR process seeks to improve the quality and cost-effectiveness of health care, and to eliminate unnecessary procedures. If reviewers are lenient, says an editorial accompanying the study, precertification UR may not eliminate inappropriate care or reduce costs as intended.

Reference

1. Kleinman LC, Boyd EA, Heritage JC. Adherence to prescribed explicit criteria during utilization review. JAMA 1997; 278:497-501.