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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.
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