The authors have not recognized that these tools are valuable for system planning as pointers to potential alternative levels of care. In utilization management they are guidelines, not rules. It would be foolish even to consider using such tools exclusively in the decision-making process about clinical management. In our studies we have repeatedly emphasized that the responsible clinician must at all times make the final judgement,^2,3 but these guidelines do help to stimulate regular review of the need for hospitalization in the interests of quality care and efficiency. The rate of inappropriate hospitalization may be debated, but it would be difficult to deny that a significant problem exists that can only be addressed by better system planning.

The ISD (Intensity of service, Severity of illness, Discharge screens) guidelines are developed and regularly revised by a more extensive panel process than that used by the authors but they do not take into account whether the more appropriate level of care (for example, outpatient diagnostics or home intravenous therapy) is actually available in the local community. Physicians become justifiably upset if a label of "inappropriate" is applied in the absence of this assessment when the alternatives simply do not exist, but planners need help in creating them.

There is, of course, no perfect tool for assessing the appropriateness of clinical services, but it would be extremely unfortunate if the unjustifiable conclusion of this paper discouraged the use of utilization review tools within the proper context.