As health care costs continue to rise, budgets continue to fall, and health consumers gain greater access to reliable information on disease conditions and interventions, there is an increased need to determine what is appropriate health management to ensure quality and responsible healthcare. Advances in technology have increased the number and types of surgical/medical interventions available to health clients. Are inappropriate interventions offered on a regular basis? Is the prescribed intervention the most appropriate?
This paper introduces the topic of appropriateness in evidenced-based healthcare and discusses how appropriateness can be assessed. What is appropriateness? Appropriateness is defined as suitable or fitting for a particular purpose, person or occasion (Webster, 1989). Appropriateness in healthcare is determined when the client’s expected health benefits exceed the expected health risks by a substantial margin, exclusive of cost (RAND, 2001) or a balance between doing good against doing harm (Muir Gray, 1997).
According to Muir Gray (1997, p.147), “a study of appropriateness is designed to reveal whether the right patient is given the right treatment at the right time by the right professional in the right place”. It is important to note that appropriateness is a subjective measure of outcomes of healthcare. Quality of care outcomes refers to correctness and appropriateness and is demonstrated by the decisions concerning the need for medical and surgical intervention. Evidence of appropriateness in healthcare is needed to improve health outcomes, balance costs, provide guidance to physicians and meet the need of the new informed health consumer.
Appropriateness is unlike effectiveness. Effectiveness refers to the degree in which an intervention achieves the objectives set (Muir Gray, 1997). One criterion of appropriateness is that of necessity. RAND Corporation has defined necessary as an intervention that is appropriate, would be improper not to make available and would be of significant benefit to the client (Muir Gray, 1997). As technology and improved methods of care are advanced, access to appropriate interventions should improve. Today some interventions are still limited such as magnetic resonance imaging (MRI) in rural communities.
Because access is limited, a criterion of necessity is used to determine who is able to access and how quickly. Therefore although use of MRI may be appropriate in diagnostics, it may be underused. Advancements in technology, interventions and clinical research will provide updated evidence which in turn would affect ratings of appropriateness (Muir Gray, 1997). Methods to determine appropriateness Methods to determine appropriateness are not only useful in determining what is appropriate care but also what is inappropriate care.
It can assist in eliminating underuse and overuse of clinical interventions. Because appropriateness is subjective, it can be difficult to measure. There is no one way or tool to determine the appropriateness of an intervention. Evidence can be assessed retrospectively, after the intervention has occurred, or prospectively, prior to the intervention and used to make a decision on which intervention to use. Evidence on appropriateness is most beneficial to local populations (Muir Gray, 1997). There are three main methods available to determine appropriateness.
These include outcomes research, clinical guidelines and the RAND/UCLA appropriateness method. Outcomes research Outcomes research examines the end results of the healthcare intervention and provides evidence on the risks, benefits and results of the intervention (AHRQ, n. d. ). Outcomes can refer to patient satisfaction, change in function or effectiveness of intervention. Research outcomes can provide evidence to make informed decisions and lead to improved quality of care. The Agency for Healthcare Research and Quality (AHRQ) provides research on outcomes for this purpose.
An example of outcomes research can be found at: http://www. ahcpr. gov/clinic/outfact. htm. Because of the complexity of assessing outcomes, more research is required to determine how best to use this evidence in determining appropriateness. Clinical Guidelines Clinical guideline statements are developed from evidence to assist healthcare practitioners in making appropriate health interventions (Woolf, Grol, Hutchinson, Eccles ; Grimshaw, 1999). The clinical guideline may be a general statement or concise instruction on which diagnostic test to order or how best to treat a specific condition.
The purpose of clinical guidelines is as a tool for making decisions that will result in more consistent and efficient care. Guidelines are not rules nor are they mandatory. The benefits of clinical guidelines include: ? Improved health outcomes ?Increased beneficial/appropriate care ?Consistency of care ?Improved patient information ?Ability to positively influence policy ?Provide direction to health care practitioners Potential limitations of clinical guidelines: ?The guideline may have been developed from inaccurate evidence ?
Patient’s need may not be the only priority, the guideline may be used to promote cost-effectiveness or special interests (Woolf et al. , 1999). An example of clinical guidelines can be viewed at: http://www. cma. ca/cmaj/guidelines. htm RAND/UCLA Method of Appropriateness RAND is a nonprofit institution that helps improve policy and decision making through research and analysis. The name RAND comes from the combination of the terms research and development. The RAND/UCLA method to determine appropriateness was developed in the 1980’s.
The method begins with a literature review for a selected medical intervention. This review sets out to determine benefits, risks, and indications for use and effectiveness. From the literature review, clinical indicators are developed. The clinical indicators must be sufficient to justify the intervention. Using the literature review and the indications, an expert panel individually rates the appropriateness of performing the intervention for each clinical indication using a rating scale of 1 to 9. 1 representing extremely inappropriate and 9 extremely appropriate.
The experts then come together in a face to face discussion. During this discussion the indictors are rated again. The panel does not have to reach consensus. For each clinical indication a mean score is obtained. A mean score of 1 ? 3 indicates broad agreement and is classified as inappropriate, 7 ? 9 represents appropriate, 4 ? 6 or disagreement of the panel on any indictor would be considered uncertain or equivocal (RAND, 2001). The RAND method is considered to be innovative, thorough and based on sound research. (Brook, 1994). Limitations of the RAND method include:
?The method ignores the patient’s needs, values, and wishes ? Overestimation of inappropriateness is common ?The method relies on physicians opinions that may not be supported by current evidence ? There is no consideration for the physician’s “gut” instinct. ?RAND scores apply to local population and are not generalizable (Nicks, 1994). RAND studies have shown rates of inappropriate use as low as 2% for coronary artery bypass graft (CABG) surgery and as high as 32% for carotid endarterectomy (RAND, 2001). References Agency of Healthcare Research and Quality. (n. d. ).
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[Online]. Available: http://www. hc-sc. gc. ca/hpb/lcdc/bcrdd/hdsc97/s02_e. html Government of the United States. (2000). Bureau census. [Online]. Available: http://www. census. gov/c2ss/www/Products/Profiles/2000/Tabular/C2SSTable1/04000US36. htm John A. Hartford Foundation. (n. d. ). [Online]. Available: http://www. jhartfound. org/ Muir Gray, J. A. (1997). Evidence-based healthcare: How to make health policy and management decisions, New York: Churchill Livingstone. Nicks, N. R. (1994). Some observations on attempts to measure appropriateness of care. [Online].
Available: http://www. bmj. com/cgi/content/full/309/6956/730? ijkey=oCspKD3Ae2wUI RAND. (n. d. ). Assessing the appropriateness of care. Research highlights. [Online]. Available: http://www. rand. org/publications/RB/RB4522/ Webster’s Encyclopaedic Unabridged Dictionary of the English Language. (1989). New York: dilithium Publishing Ltd. Woolf, S. H. , Grol, R. , Hutchinson, A. , Eccles, M. , ; Grimshaw, J. (1999). Clinical guidelines: Potential benefits, limitations and harms of clinical guidelines. [Online]. Available: http://www. bmj. com/cgi/content/full/318/7182/527?