FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 323:1173-1177 October 25, 1990 Number 17 Next

	Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

Abstract

BACKGROUND AND METHODS. In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately. RESULTS. In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01). CONCLUSIONS. Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.

Source Information

Health Sciences Program, Rand Corporation, Santa Monica, Calif. 90406.

This article has been cited by other articles:

• Brown, H. J., Miles, P. V., Perelman, R. H., Stockman, J. A. III (2009). A Continuum of Competency Assessment: The Potential for Reciprocal Use of the Accreditation Council for Graduate Medical Education Toolbox and the Components of the American Board of Pediatrics Maintenance-of-Certification Program. Pediatrics 123: S56-S58 [Abstract] [Full Text]  
• Miles, P. (2009). Health Information Systems and Physician Quality: Role of the American Board of Pediatrics Maintenance of Certification in Improving Children's Health Care. Pediatrics 123: S108-S110 [Abstract] [Full Text]  
• Murphy, T. P., Soares, G., Kim, M. (2004). Increase in Utilization of Percutaneous Renal Artery Interventions by Medicare Beneficiaries, 1996-2000. Am. J. Roentgenol. 183: 561-568 [Abstract] [Full Text]  
• Sheikh, K., Bullock, C. (2003). Sex differences in carotid endarterectomy utilization and 30-day postoperative mortality. Neurology 60: 471-476 [Abstract] [Full Text]  
• Chernew, M. (2001). General Equilibrium and Marketability in the Health Care Industry. Journal of Health Politics, Policy and Law 26: 885-898  
• Kressin, N. R., Petersen, L. A. (2001). Racial Differences in the Use of Invasive Cardiovascular Procedures: Review of the Literature and Prescription for Future Research. ANN INTERN MED 135: 352-366 [Abstract] [Full Text]  
• Johnston, S. C., Fung, L. H., Gillum, L. A., Smith, W. S., Brass, L. M., Lichtman, J. H., Brown, A. N., Wang, D. Z. (2001). Utilization of Intravenous Tissue-Type Plasminogen Activator for Ischemic Stroke at Academic Medical Centers : The Influence of Ethnicity Editorial Comment : It Is Time to Implement Stroke Practice Improvement Programs and Prevent the Racial Disparity in Stroke Care. Stroke 32: 1061-1068 [Abstract] [Full Text]  
• Williams, G. R., Jiang, J. G., Matchar, D. B., Samsa, G. P. (1999). Incidence and Occurrence of Total (First-Ever and Recurrent) Stroke. Stroke 30: 2523-2528 [Abstract] [Full Text]  
• Ringel, S. P. (1999). Practicing neurology: A delicate balance. Neurology 52: 1526-1526 [Full Text]  
• Karp, H. R., Flanders, W. D., Shipp, C. C., Taylor, B., Martin, D. (1998). Carotid Endarterectomy Among Medicare Beneficiaries : A Statewide Evaluation of Appropriateness and Outcome. Stroke 29: 46-52 [Abstract] [Full Text]  
• Horner, R. D., Hoenig, H., Sloane, R., Rubenstein, L. V., Kahn, K. L. (1997). Racial Differences in the Utilization of Inpatient Rehabilitation Services Among Elderly Stroke Patients. Stroke 28: 19-25 [Abstract] [Full Text]  
• Ringel, S. P., Hughes, R. L. (1996). Evidence-Based Medicine, Critical Pathways, Practice Guidelines, and Managed Care: Reflections on the Prevention and Care of Stroke. Arch Neurol 53: 867-871 [Abstract]  
• Markus, T., Booth, P. W. (1995). Managing cleft lip and palate. BMJ 311: 765-765 [Full Text]  
• Arndt, M., Bradbury, R. C., Golec, J. (1995). Indications for Hysterectomy: Variation within and Across Hospitals. Med Care Res Rev 52: 342-363 [Abstract]  
• Gillum, R. F. (1995). Epidemiology of Carotid Endarterectomy and Cerebral Arteriography in the United States. Stroke 26: 1724-1728 [Abstract] [Full Text]  
• Axon, A T R, Bell, G D, Jones, R H, Quine, M A, McCloy, R F (1995). Guidelines on appropriate indications for upper gastrointestinal endoscopy. BMJ 310: 853-856 [Full Text]  
• Daniels, N., Sabin, J. E. (1995). The Yin and Yang of Health Care System Reform: Professional and Political Strategies for Setting Limits. Arch Fam Med 4: 67-71 [Abstract]  
• Berwick, D. M. (1994). Eleven Worthy Aims for Clinical Leadership of Health System Reform. JAMA 272: 797-802 [Abstract]  
• Longo, D. R., Daugird, A. J. (1994). Measuring the Quality of Care: Reforming the Health Care System. American Journal of Medical Quality 9: 104-115 [Abstract]  
• Oddone, E. Z., Horner, R. D., Monger, M. E., Matchar, D. B. (1993). Racial Variations in the Rates of Carotid Angiography and Endarterectomy in Patients With Stroke and Transient Ischemic Attack. Arch Intern Med 153: 2781-2786 [Abstract]  
• Phelps, C. E. (1993). The Methodologic Foundations of Studies of the Appropriateness of Medical Care. NEJM 329: 1241-1245 [Full Text]  
• Pearson, M. L., Kahn, K. L., Harrison, E. R., Rubenstein, L. V., Rogers, W. H., Brook, R. H., Keeler, E. B. (1992). Differences in Quality of Care for Hospitalized Elderly Men and Women. JAMA 268: 1883-1889 [Abstract]  
• Zelkovic, M. A., Nicholas, G. G., Reed, J. F. (1992). Indications for Carotid Endarterectomy: Surgeons vs Neurologists. VASC ENDOVASCULAR SURG 26: 642-648 [Abstract]  
• Fahey, D. F. (1992). Projected Responses to Changes in Physician RBRVS Reimbursement: Induced-Demand Theory versus Contingency Theory. Med Care Res Rev 49: 67-91  
• Hadorn, D. C., Brook, R. H. (1991). The Health Care Resource Allocation Debate: Defining Our Terms. JAMA 266: 3328-3331 [Abstract]  
• Rolph, J. E., Kravitz, R. L., McGuigan, K. (1991). Malpractice Claims Data as a Quality Improvement Tool: II. Is Targeting Effective?. JAMA 266: 2093-2097 [Abstract]