Background Evaluations of the appropriateness of medical careare important to monitor the quality of care and to containcosts and enhance safety by reducing inappropriate care. Experts'views are usually incorporated into evaluations of appropriateness.However, practicing physicians may not concur with these views,and physicians' clinical backgrounds may influence their beliefs.
Methods We asked 1058 internists, family practitioners, andcardiologists in California, Florida, New York, Pennsylvania,and Texas to rate the appropriateness of coronary angiographyafter acute myocardial infarction for 20 common indications.Nine clinical experts also rated these indications using anestablished consensus method.
Results For 17 of the 20 indications, median ratings of surveyedphysicians and the expert panel agreed within 1 unit on a 9-unitscale. Patients' older age had a negative effect on ratingsby the expert panel but not on ratings by surveyed physicians.In multivariable analyses of surveyed physicians, cardiologistsrated angiography as significantly more appropriate than didprimary care physicians for complicated indications, and foruncomplicated indications cardiologists who performed invasiveprocedures gave higher appropriateness ratings for angiographythan did cardiologists who did not perform such procedures andprimary care physicians. For uncomplicated indications, physiciansfrom hospitals providing coronary angioplasty and bypass surgeryrated angiography as more appropriate than physicians from otherhospitals. Physicians from New York and those employed by healthmaintenance organizations rated angiography as less appropriatethan other physicians.
Conclusions Surveyed physicians agreed with clinical expertsabout the appropriateness of coronary angiography after myocardialinfarction for most indications, indicating that well-designedexpert panels can closely reflect the views of practicing physicians.Variations in beliefs among practicing physicians suggest thatevaluations of medical practice should incorporate the viewsof a range of relevant types of physicians.
Source Information
From the Department of Medicine, Division of General Medicine and Primary Care, Section on Health Services and Policy Research (J.Z.A.), and the Department of Radiology (B.J.M.), Brigham and Women's Hospital and Harvard Medical School; the Department of Health Care Policy, Harvard Medical School (J.Z.A., M.B.L., S.-L.T.N., E.G., B.J.M.); and the Department of Biostatistics, Harvard School of Public Health (S.-L.T.N.) — all in Boston.
Address reprint requests to Dr. Ayanian at the Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115.
Assessing the Appropriateness of Medical Care
Wassertheil-Smoller S., Tobin J., Steingart R., Hsu J., Black N., Ayanian J. Z., Shekelle P. G., Park R.E., Naylor C. D.
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N Engl J Med 1998;
339:1478-1481, Nov 12, 1998.
Correspondence
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