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Abstract

Health systems should function in such a way that the amount of inappropriate care is minimized, while at the same time stinting as little as possible on appropriate and necessary care. The ability to determine and identify which care is overused and which is underused is essential to this functioning. To this end, the "RAND/UCLA Appropriateness Method" was developed in the 1980s. It has been further developed and refined in North America and, increasingly, in Europe. The rationale behind the method is that randomized clinical trials — the "gold standard" for evidence-based medicine — are generally either not available or cannot provide evidence at a level of detail sufficient to apply to the wide range of patients seen in everyday clinical practice. Although robust scientific evidence about the benefits of many procedures is lacking, physicians must nonetheless make decisions every day about when to use them. Consequently, a method was developed that combined the best available scientific evidence with the collective judgment of experts to yield a statement regarding the appropriateness of performing a procedure at the level of patient-specific symptoms, medical history, and test results. This manual presents step-by-step guidelines for conceptualising, designing, and carrying out a study of the appropriateness of medical or surgical procedures (for either diagnosis or treatment) using the RAND/UCLA Appropriateness Method. The manual distills the experience of many researchers in North America and Europe and presents current (as of the year 2000) thinking on the subject. Although the manual is self-contained and complete, the authors do not recommend that those unfamiliar with the RAND/UCLA Appropriateness Method independently conduct an appropriateness study; instead, they suggest "seeing one" before "doing one." To this end, contact information is provided to assist potential users of the method.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Selecting a Topic

  • Chapter Three

    Review and Synthesis of the Literature

  • Chapter Four

    Developing the List of Indications and Definitions

  • Chapter Five

    The Expert Panel

  • Chapter Six

    The Rating Process: Appropriateness and Necessity

  • Chapter Seven

    Chairing an Expert Panel

  • Chapter Eight

    Classifying Appropriateness

  • Chapter Nine

    Software Tools for Data Processing and Analysis

  • Chapter Ten

    Applying Appropriateness Criteria Retrospectively to Measure Overuse

  • Chapter Eleven

    Applying Necessity Criteria to Measure Underuse

  • Chapter Twelve

    Applying Appropriateness Criteria Prospectively to Assist in Decision-Making

  • Chapter Thirteen

    Methodological Issues

  • Annex I

    Members of the European Union BIOMED Concerted Action on "A Method to Integrate Scientific and Clinical Knowledge to Achieve the Appropriate Utilisation of Major Medical and Surgical Procedures"

  • Annex II

    List of Acronyms

Research conducted by

The research described in this report was prepared for Directorate General XII, European Commission and conducted within RAND Health and RAND Europe.

This report is part of the RAND Corporation monograph report series. The monograph/report was a product of the RAND Corporation from 1993 to 2003. RAND monograph/reports presented major research findings that addressed the challenges facing the public and private sectors. They included executive summaries, technical documentation, and synthesis pieces.

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