National Academies Press: OpenBook

Clinical Practice Guidelines: Directions for a New Program (1990)

Chapter: The Committee's Definition: Medical Review Criteria

« Previous: Professional and Technical Usage
Suggested Citation:"The Committee's Definition: Medical Review Criteria." Institute of Medicine. 1990. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: The National Academies Press. doi: 10.17226/1626.
Page 44

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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 phrases—for example, caveat emptor—are 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.

Next: Common Usage: The Dictionary »
Clinical Practice Guidelines: Directions for a New Program Get This Book
Buy Paperback | $50.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF
  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook,'s online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!