The Methodologic Foundations of Studies of the Appropriateness of Medical Care

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Abstract
As health care costs continue to increase rapidly, both health care providers and consumers have expressed concern that the additional resources used for health services do not provide commensurate increases in health benefits. Adding fuel to this concern, a number of disquieting studies have estimated the rates of “inappropriate” use in a variety of settings of a variety of procedures such as coronary angiography, carotid endarterectomy, endoscopy, and coronary-artery bypass graft surgery1-4. The estimated rates of inappropriate treatment have ranged from about 15 to 30 percent, reaching as high as 40 percent for particular procedures at individual institutions. Recent studies estimated a rate of 16 percent for inappropriate hysterectomy in seven health maintenance organizations,5 a rate of 24 percent for inappropriate days spent in a Canadian children's hospital,6 and a rate of 23 percent for inappropriate hospitalizations for measles7. The only results that run counter to these high rates have come from recent studies of coronary-artery bypass graft surgery (2 percent inappropriate use),8 percutaneous transluminal coronary angioplasty (4 percent),9 and angioplasty (4 percent)10 in New York. One study concluded that “a substantial fraction of hospitalization is potentially avoidable”11. A leader in studies of medical appropriateness has stated, “If one could extrapolate from the available literature, then perhaps one fourth of hospital days, one fourth of procedures, and two fifths of medications could be done without”12. If this is true, then the country's annual health care bill could be cut by perhaps $100 billion without harm to the public.