RISK, MOTIVES, AND STYLES OF UTILIZATION REVIEW - A CROSS-CONDITION COMPARISON

In the United States various forms of managed care have been introduce d to control the use of expensive medical services. One of the most pr ominent involves utilization review of hospital admissions. While revi ewing the appropriateness of inpatient treatment is appealing in princ iple, its application is made difficult by clinical uncertainty. Manag ed care plans develop and implement review criteria often without the guidance of clear clinical norms of treatment. Under these conditions, we suggest that utilization review organizations (UROs) can be expect ed to develop ''styles'' of review that respond to clinical uncertaint y, influenced by their experience, professional orientation, and finan cial incentives. Two review styles are explored in this paper: standar dization, where the URO reduces the variance in clinical practices by eliminating those practices that deviate from professional norms and s tringency, whereby the URO shifts the distribution of clinical practic e as it tries to change the professional norms of practice. Data from a 1992-1993 national survey of utilization review organizations are us ed to test whether UROs have review styles that systematically respond to organizational attributes, economic pressures, and clinical uncert ainty associated with three medical conditions: cardiac catheterizatio n, low back pain; and adolescent depression. UROs were found to adopt more stringent review strategies for conditions with weaker norms of a ppropriate treatment. Financial incentives and organizational experien ce are positively related to greater stringency. Standardization respo nds to professional orientation and organizational experience. Variati on in the review styles of UROs has implications for the resulting dis tribution of clinical practices as well as the equity of access to med ical care. (C) 1998 Elsevier Science Ltd. All rights reserved.