How valid are utilization review tools in assessing appropriate use of acute care beds?

Background: Despite their widespread acceptance, utilization review tools, which were designed to assess the appropriateness of care in acute care hos pitals, have not been well validated in Canada. The aim of this study was t o assess the validity of 3 such tools - ISD (Intensity of service, Severity of illness, Discharge screens), AEP (Appropriateness Evaluation Protocol) and MCAP (Managed Care Appropriateness Protocol) - as determined by their a greement with the clinical judgement of a panel of experts. Methods: The cases of 75 patients admitted to an acute cardiology service w ere reviewed retrospectively. The criteria of each utilization review tool were applied by trained reviewers to each day the patients spent in hospita l. An abstract of each case prepared in a day-by-day format was evaluated i ndependently by 3 cardiologists, using clinical judgement to decide the app ropriateness of each day spent in hospital. Results: The panel considered 92% of the admissions and 67% of the subseque nt hospital days to be appropriate. The ISD underestimated the appropriaten ess rates of admission and subsequent days; the AEP and MCAP overestimated the appropriateness rate of subsequent days in hospital. The kappa statisti c of overall agreement between tool and panel was 0.45 for ISD, 0.24 for MC AP and 0.25 for AEP, indicating poor to fair validity of the tools. Interpretation: Published validation studies had average kappa values of 0. 32-0.44 (i.e., poor to fair) for admission days and for subsequent days in hospital for the 3 tools. The tools have only a low level of validity when compared with a panel of experts, which raises serious doubts about their u sefulness for utilization review.