It’s no surprise that inappropriate care decisions can negatively impact patients, but they also place a strain on the entire health care system. At a time when the demand for health care providers and services exceed the current supply, it’s critical to manage resources effectively to help ensure access to care. According to a 2022 analysis published by the JAMA Health Forum, 20% to 30% of health care services are overutilized, and unexplained care variances and slow adoption of best practices continue.
When patients are placed in the wrong care setting, such as admitting them to the hospital when outpatient care would be sufficient, not only does it increase the patient’s risk of infection, but it raises overall health care costs. Hospital-acquired infections cost the health care system between $35.7 and $45 billion annually.
Beyond infection risks, unnecessary tests, procedures, and interventions can expose patients to avoidable harm and stress. Research shows up to 30% of diagnostic tests in the U.S. are unnecessary, with 4 to 5 billion tests performed each year. Surgical errors account for 10% of preventable patient harm, highlighting the importance of practicing evidenced-based medicine.
To address these challenges, an evidence-based care strategy that ensures patients receive appropriate and effective care while reducing costs for all involved is critical —a health system grounded in the principles of value-based care.
Enhancing clinical decision making and driving appropriate care
Providers who implement evidence-based practices have seen up to a 21% reduction in hospital readmissions, contributing to better patient outcomes.
To help ensure clinically appropriate admissions, clinical decision support tools provide evidence-based criteria as a primary screening mechanism to determine the appropriate level of care based on individual patient conditions. Long-established tools, like Optum’s InterQual® suite of evidence-based criteria, are rigorously developed and regularly updated to reflect the current state of medical literature, evidence and standards of care. More than 4,500 hospitals, health plans and government agencies use InterQual Criteria when making decisions about care and resource use.
These tools help case managers and utilization reviewers advocate for quality of care by looking holistically at factors like symptoms, medical and behavioral issues, social factors, support systems, functional abilities, and treatment history. They also assist in managing cases to improve care quality, facilitate care, and plan for transitions and discharges, all within the case manager’s workflow.
“The InterQual clinical guidelines provide our nurse care managers with tools to track and manage discharge readiness and hospital length of stay and help to ensure our hospital system aligns with payer requirements throughout the utilization review process,” said Rob Shutter, director of utilization management at New York City Health and Hospitals Corporation.
Implementing evidence-based criteria enhances alignment with health plan standards. This approach not only reduces denial rates but fosters better collaboration between payers and providers, leading to increased transparency and ultimately a more positive patient experience.
Evidence-based content development process
For these tools to continue to be useful and accurate, the criteria must be updated and reviewed frequently to reflect the latest medical and behavioral research and clinical practices.
For example, the InterQual content development process is systematic and comprehensive, following evidence-based medicine principles to create objective criteria reflecting best clinical practices. Physician-led teams of more than 50 clinicians continuously review literature and conduct extensive appraisals to validate that the highest quality of evidence is used in development. The process includes extensive literature references, allowing for transparency into the evidentiary basis of the criteria.
To avoid bias, initial drafts are sent for external feedback and validation through a peer review process. This involves panels drawn from a pool of over 1,200 actively practicing clinicians including physicians, psychologists, pharmacists, advance practice nurses and therapists, who are screened for conflicts of interest and credentialed by Optum every two years.
“The role of an external peer reviewer is to validate the InterQual Criteria based on what we experience in every day clinical practice while delivering life-sustaining and compassionate care. We ensure the criteria aligns with the evidence and address our patients’ complex needs,” said Holly Gardner, MD, practicing emergency physician in Columbus, Indiana and external peer reviewer for InterQual Criteria. “This helps protect against bias and promotes accuracy and objectivity to drive positive change for those on the front lines and the patients we serve.”
Continuous innovation with the latest evidence
Advanced technologies and data analytics play a crucial role in the future of health care, as they enhance evidence-based practices and support optimal utilization of finite resources. Clinical decision support tools help providers make informed decisions, while offering proactive insights, automating manual processes and connecting payers and providers seamlessly. These resources allow clinicians to focus on providing quality patient care, leading to better outcomes.
Laura Coughlin, RN, BSN, MBA, is vice president of clinical innovation and development at Optum Insight
