The pressure on hospital managers to reduce costs is unrelenting and cutting back on acute-care bed use is an important part of controlling spending. But new research suggests that several utilization-review tools - which hospital managers use to assess the appropriateness of patient stays - may not be reliable gauges.

In a study published in the Canadian Medical Association Journal (Vol. 162, Issue 13) a group of researchers from Montreal's Sir Mortimer B. Davis-Jewish General Hospital tested the Intensity of Service, Severity of Illness Discharge Screens (ISD) the Managed Care Appropriateness Protocol (MCAP) and the Appropriateness Evaluation Protocol (AEP) by reviewing the files of 75 patients admitted to the coronary care unit.

The three protocols have been widely used in Canada, but compared to assessments by a panel of doctors, all three measures come up short, the study says. While the study's panel of cardiologists felt 92% of admissions and 67% of days subsequently spent in hospital were appropriate, the ISD tended to underestimate the appropriateness of the subsequent days, while the others both overestimated compared to the panel.

The differences between the panel's findings and those of the review tools were wide enough to raise questions on whether the protocols should be used at all, the study warns. In an interview, lead author Norman Kalant admitted that while reviews by panels are preferable, it can be difficult to find physicians with the time to participate.

Still, there is a reasonable alternative, Dr. Kalant said. "It's conceivable that it might be better to select a group of patients whose lengths of stay are longer than they should be, or than those at peer hospitals, then examine a sampling of those patients to see if you can find reasons for their extra time. You still need a panel, but they don't have to give up as much time."

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