An Outcomes Analysis Approach to Utilization Management: Quality Assessment of Appropriateness of Specialty Referrals

Abstract

This report illustrates some methods by which to identify, guide, and develop acceptable levels of ex pected outcomes, defined as the validity or appropri ateness of specialty referrals or procedures, through utilization management case studies and interven tions. Outcomes variables may be used as standard ized ongoing measures of cost-effectiveness and qual ity of health care services, focusing on appropriate ness of utilization of specialty resources and health care technology. Community, regional, and national standards for such measures are currently being de veloped and evaluated for assessing the appropriate ness of the use of health care technology. These stand ards for desired or expected outcomes need to become an integral part of utilization management as well as quality assessment and improvement, and are very helpful tools for developing specific interventions to be used for improving upon and documenting the cost- effective delivery of care within health services or ganizations.