An outcomes analysis approach to utilization management: quality assessment of appropriateness of specialty referrals

This report illustrates some methods by which to identify, guide, and develop acceptable levels of expected outcomes, defined as the validity or appropriateness of specialty referrals or procedures, through utilization management case studies and interventions. Outcomes variables may be used as standardized ongoing measures of cost-effectiveness and quality of health care services, focusing on appropriateness of utilization of specialty resources and health care technology. Community, regional, and national standards for such measures are currently being developed and evaluated for assessing the appropriateness of the use of health care technology. These standards 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 organizations.