The Reproducibility of a Method to Identify the Overuse of Medical Procedures

Published in: The New England Journal of Medicine, v. 338, no. 26, June 25, 1998, p. 1888-1895

by Paul G. Shekelle, James P. Kahan, Steven J. Bernstein, Lucian L. Leape, Caren Kamberg, Rolla Edward Park

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To assess the overuse and underuse of medical procedures, various methods have been developed, but their reproducibility has not been evaluated. This study estimates the reproducibility of one commonly used method. The authors performed a parallel, three-way replication of the RAND-University of California at Los Angeles appropriateness method as applied to two medical procedures, coronary revascularization and hysterectomy. Three nine-member multidisciplinary panels of experts were composed for each procedure by stratified random sampling from a list of experts nominated by the relevant specialty societies. Each panel independently rated the same set of clinical scenarios in terms of the appropriateness of the relevant procedure on a risk-benefit scale ranging from 1 to 9. Final ratings were used to classify the procedure in each scenario as necessary or not necessary (to evaluate underuse) and inappropriate or not inappropriate (to evaluate overuse). Reproducibility was measured by overall agreement and by the kappa statistic. The criteria for underuse and overuse derived from these ratings were then applied to real populations of patients who had undergone coronary revascularization or hysterectomy. The authors conclude that the appropriateness method is far from perfect. Appropriateness criteria may be useful in comparing levels of appropriate procedures among populations but should not by themselves be used to direct care for individual patients.

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