Determining appropriateness for rehabilitation or other subacute care: is there a role for utilisation review?

BACKGROUND: Rehabilitation and other forms of subacute care play an important role in the Australian health care system, yet there is ambiguity around clinical definitions of subacute care, how it differs from acute care, where it is best done and what resources are required. This leads to inconsistent and often poorly defined patient selection criteria as well as a lack of research into efficient models of care. METHODS: A literature review on the potential role of utilisation review in defining levels of care and in facilitating appropriate care, with a focus on the interface between acute care and rehabilitation. RESULTS: In studies using standardised utilisation review tools there is consistent reporting of high levels of 'inappropriate' bed days in acute care settings. These inappropriate bed days include both inappropriate admissions to acute care and inappropriate continuing days of stay. While predominantly an instrument of payers in the United States, concurrent utilisation review programs have also been used outside of the US, where they help in the facilitation of appropriate care. Some utilisation review tools also have specific criteria for determining patient appropriateness for rehabilitation and other subacute care. CONCLUSION: The high levels of 'inappropriate' care demonstrated repeatedly in international studies using formal programs of utilisation review should not be ignored in Australia. Utilisation review tools, while predominantly developed in the US, may complement other Australian patient flow initiatives to improve efficiency while maintaining patient safety. They could also play a role in the identification of patients who may benefit from transfer from acute care to another type of care and thus be an adjunct to physician assessment. Testing of the available utilisation review tools in the Australian context is now required.