Goldman R L, Weir C R, Turner C W, Smith C B
VA Central Office, Salt Lake City, Utah.
Am J Psychiatry. 1997 Mar;154(3):349-54. doi: 10.1176/ajp.154.3.349.
This study examined the validity of four psychiatric utilization management criteria sets: the 1992 and 1993 InterQual Intensity, Severity, and Discharge (ISD) criteria, the Managed Care Appropriateness Protocol, and an instrument developed by the Department of Veterans Affairs (VA).
The appropriateness of acute care admission and continued stay for 70 randomly selected VA psychiatric inpatients was retrospectively assessed with each criteria set. The sensitivity and specificity of each instrument were evaluated by comparing its assessments to the consensus of judgments of a panel of expert psychiatrists who reviewed the same cases. Sensitivity was defined as the proportion of admissions or continued-stay days the panel found appropriate for acute care that the criteria judged to be appropriate for acute care; specificity was the proportion the panel found inappropriate for acute care that the criteria judged to be inappropriate for acute care.
For admissions, there were only minor differences in the validity of the four criteria sets as assessed by agreement with the panel's judgments. For each of 4 continued-stay days studied, either the sensitivity or specificity of the 1993 InterQual ISD criteria was below 0.30. The specificity of the 1992 InterQual ISD criteria was below 0.60 for 2 days. In contrast, for the Managed Care Appropriateness Protocol, sensitivity was 0.73-0.93 and specificity was 0.78-0.88 over the 4 days.
The findings raise major concerns about the validity of the widely used InterQual ISD psychiatry criteria, suggest that the Managed Care Appropriateness Protocol may be a useful tool for psychiatric utilization management, strongly underline the need to validate all criteria used to assess medical care, and support the appropriateness of the procedures used to perform these assessments.
本研究检验了四种精神科利用管理标准集的有效性：1992年和1993年的InterQual强度、严重程度及出院（ISD）标准、管理式医疗适宜性协议以及退伍军人事务部（VA）制定的一项工具。
采用每种标准集对70名随机选取的VA精神科住院患者的急性护理入院及持续住院的适宜性进行回顾性评估。通过将每种工具的评估结果与审查相同病例的专家精神科医生小组的判断共识进行比较，来评估每种工具的敏感性和特异性。敏感性定义为专家小组认为适合急性护理的入院或持续住院天数中，该标准判定为适合急性护理的比例；特异性是指专家小组认为不适合急性护理的天数中，该标准判定为不适合急性护理的比例。
对于入院情况，根据与专家小组判断的一致性评估，四种标准集的有效性仅有微小差异。在所研究的4个持续住院日中，1993年InterQual ISD标准的敏感性或特异性在每个住院日都低于0.30。1992年InterQual ISD标准在2个住院日的特异性低于0.60。相比之下，对于管理式医疗适宜性协议，在这4个住院日中，敏感性为0.73 - 0.93，特异性为0.78 - 0.88。
这些发现引发了对广泛使用的InterQual ISD精神科标准有效性的重大担忧，表明管理式医疗适宜性协议可能是精神科利用管理的有用工具，强烈强调了验证所有用于评估医疗护理的标准的必要性，并支持进行这些评估所采用程序的适宜性。
