Appropriateness criteria: a useful tool for the cardiologist
- Dr P G Shekelle, The RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA; shekelle{at}rand.org
- Accepted 18 December 2008
- Published Online First 18 December 2008
An increasing number of publications have described appropriateness criteria for the use of diagnostic and therapeutic procedures in cardiology. In this editorial I will discuss how appropriateness criteria are developed, and the evidence for their usefulness in the practice of cardiology.
The Appropriateness Method was developed as a pragmatic solution to the problem of assessing for which patients certain surgical and medical procedures are “appropriate”. In this context, “appropriate” means that the benefits sufficiently exceed the risks so that the procedure is worth doing. Twenty-five years ago geographical variations in the use of procedures were considerable. A hypothesis at that time was that any rate of use of a procedure higher than the lowest identified rate probably represented “inappropriate” overuse of the procedure. Investigators at RAND and UCLA set out to test this hypothesis. They hoped to compare the rate of appropriate and inappropriate use at high- and low-use geographical sites, assuming that “appropriate” use for a procedure could be determined from a review of published medical reports. Having been disabused of this notion after examining published reports on six procedures, the investigators were left with the problem of how to make such assessments.
Several fundamental concepts helped to shape their solution:
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Medical publications alone are insufficient for judgments to be made about appropriateness for most potential indications for any procedure. Clinical judgment is needed to “fill in the gaps”.
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All the clinical disciplines involved in the care of a certain condition have something to contribute to the determination of appropriateness. Clinical input should come from a multidisciplinary group.
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Patients need to be described in sufficient clinical detail such that what is being rated is sufficiently homogeneous with respect to risks and benefits that the rating can be meaningfully applied to all people who meet the criteria.
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The results should …
