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DEFINITIONS OF KEY TERMS 44 The Committee's Definition: Medical Review Criteria Medical review criteria are systematically developed statements that can be used to assess the appropriateness of specific health care decisions, services, and outcomes. For medical review criteria, the committee definition stresses the evaluation of health care processes and outcomes rather than assistance to practitioners and patients in making decisions. The definition offered here is reasonably consistent with legislative language and most professional and common usage. It is also reasonably succinct and not tautological. As noted earlier in this chapter, the committee's definition of appropriate care does not require that judgments be made about the cost-effectiveness of particular clinical practices. 6 Neither does the definition preclude it. Medical review criteria have many different uses and users. They may be used (1) prospectively, for example, to review a proposed hospital admission or surgical procedure; (2) concurrently, for instance, to assess the need for continued hospitalization; or (3) retrospectively, for example, to make decisions about insurance claims. Criteria-based reviews may focus on patterns of practice or on individual cases of care. For example, reviewers concerned primarily with assessing the quality of care may concentrate on retrospective analyses of patterns of care; they may also rely heavily on case-finding screens applied retrospectively to identify individual potential problems for further evaluation using more detailed criteria (IOM, 1990). Users more concerned with cost management have increasingly emphasized review criteria that can be applied prospectively on a case- by-case basis to certain relatively expensive procedures (IOM, 1989). Traditional criteria for judging the process of care most often specify only the things that should be done and ignore things that should not be done. In contrast, criteria used for insurance claims review tend to screen for the inappropriate service rather than list everything that is appropriate. (Claims review may also include a variety of nonclinical matters, such as whether the general category of service, setting, and provider was covered under a patient's benefit plan and whether the service was correctly coded.) As noted earlier, some practice guidelines may translate into or be used as medical review criteria in a straightforward fashion (just as some foreign words and phrasesâfor example, caveat emptorâare easily used by English speakers). For practical or technical reasons, other guidelines may be more difficult or less suitable for use in this way. Of the initial conditions being 6 A recent IOM report (1989) noted that most private payers and review organizations claim that their retrospective reviews of care for specific patients focus on clinical factors, not costs, and that their emphasis is on detecting clearly inappropriate care.
