Screening for utilization review: on the use of explicit criteria and non-physicians in case selection.

Abstract

Evaluation is an increasingly important, time-consuming part of the medical care system. Use of explicit criteria in making such judgments has been recommended to promote consistency and fairness. This paper extends the use of criteria to screening so as to reduce the time physicians spend in evaluation. Can criteria be explicit and complete enough so that a suitably trained nonphysician can use them with acceptable accuracy? If so, physicians could concentrate on cases selected by the non-physicians, rather than on cases arbitrarily or randomly selected.

Performance and Sociodemographic Determinants of Excess Outpatient Demand of Rural Residents in China: A Cross-Sectional Study

“…Two internationally used methods for evaluating the appropriateness of excess healthcare demand are the recommendation method (implicit criteria) [ 38 , 39 ] and the indicator method (explicit diagnosis-specific criteria [ 40 ]. The former requires senior clinicians to review medical records and judge whether hospitalization is appropriate, and this decision depends entirely on the clinicians’ knowledge, experience and skills.…”

Determinants of Inappropriate Admissions in County Hospitals in Rural China: A Cross-Sectional Study

“…For technical reasons, oversight of the appropriateness of admission is relatively difficult [ 8 , 9 , 10 ]. Multiple studies have focused on assessing inappropriate admissions using expert evaluation methods [ 11 ], the opinion of the assessment team or rapid-response team [ 12 ], an intensity–severity–discharge review system with adult criteria [ 13 , 14 ], or an appropriateness evaluation protocol (AEP) [ 15 , 16 ]. AEP is considered the most effective and widely used technique, as it includes both disease severity and requirements for services as indicators of appropriate hospitalisation.…”

Current level and determinants of inappropriate admissions to township hospitals under the new rural cooperative medical system in China: a cross-sectional study

“…Two methods are internationally accepted in evaluating admission rationality, explicit diagnosis-specific criteria (EDC) [ 20 ] and implicit criteria [ 21 , 22 ]. The classification of disease diagnosis is not included in EDC.…”