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Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography
R H Brook1, R E Park, M R Chassin
1Health Sciences Program, Rand Corporation, Santa Monica, Calif. 90406.
Insights
Medical procedure appropriateness is difficult to predict using patient, physician, or hospital factors. Direct assessment is needed to improve care quality for procedures like angiography and endarterectomy.
Area of Science:
- Health Services Research
- Medical Appropriateness
- Quality of Care
Background:
- A significant proportion of procedures like coronary angiography, upper gastrointestinal endoscopy, and carotid endarterectomy are performed for reasons that are not medically appropriate.
- Understanding factors influencing procedural appropriateness is crucial for improving healthcare quality.
Purpose of the Study:
- To investigate whether patient, physician, or hospital characteristics predict the appropriateness of selected medical procedures.
- To identify factors associated with appropriate use of coronary angiography, upper gastrointestinal endoscopy, and carotid endarterectomy.
Main Methods:
- Analysis of a nationally representative population aged 65 years or older.
- Examination of patient demographics (age, sex, race), physician factors (age, board certification, experience), and hospital attributes (teaching status, ownership, size).
Main Results:
- Patient, physician, and hospital characteristics explained less than 4% of the variability in procedural appropriateness.
- Teaching hospital status was associated with increased appropriateness for all three procedures.
- Older, more affluent patients were more likely to receive appropriate angiographies.
- Higher surgeon procedure volume was linked to decreased appropriateness for carotid endarterectomy.
Conclusions:
- Predicting the appropriateness of medical procedures based on easily obtainable characteristics is challenging.
- Improving the appropriateness of care requires direct assessment at the individual patient, hospital, and physician level.
Background And Methods:
In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately.
Results:
In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01).
Conclusions:
Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.