The reproducibility of a method to identify the overuse and underuse of medical procedures
The reproducibility of a method to identify the overuse and underuse of medical procedures
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DOI：
10.1056/nejm199806253382607
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发表时间：
1998-06-25
影响因子：
158.5
通讯作者：
Park, RE
中科院分区：
文献类型：
--
作者：
Shekelle, PG;Kahan, JP;Park, RE
为了评估医疗程序的过度使用和使用不足，已经开发了各种方法，但尚未评估其可重复性。这项研究估计的再现性的一个常用的methods.Methods我们进行了平行，三向复制的RAND-加州大学洛杉矶适当的方法，适用于两个医疗程序，冠状动脉血运重建术和子宫切除术。通过从相关专业协会提名的专家名单中分层随机抽样，为每个程序组成三个由九名成员组成的多学科专家小组。每个小组在1 - 9的风险-受益量表上对同一组临床场景的相关程序的适当性进行独立评级。最终评级用于将每种情况下的手术分类为必要或不必要（以评价使用不足）和不适当或不适当（以评价过度使用）。通过总体一致性和Kappa统计量来衡量生殖能力。从这些评级中得出的未充分使用和过度使用的标准，然后应用到真实的人群的患者谁经历了冠状动脉血运重建或hectors.Results之间的协议率的三个冠状动脉血运重建面板分别为95，94和96%的不适当使用的情况下，93，92和92%的必要使用的情况下。三个子宫切除术小组之间的协议是88%，70%和74%的不当使用的情况。没有评估涉及必要使用子宫切除术的情况。冠状动脉血运重建术和子宫切除术检测过度使用的三因素kappa统计量分别为0.52和0.51。检测冠状动脉血运重建术使用不足的三因素kappa统计量为0.83。个别小组的标准应用到真实的患者人群中，导致100%的变化的比例的情况下归类为不适当的和20%的变化的比例的情况下归类为necessary.Conclusions适当的方法是远远不够完美的。适当的标准可能有助于比较人群中适当程序的水平，但不应单独用于指导个别患者的护理。（N Engl J Med 1998; 338：1888-95.）(C)1998年，马萨诸塞州医学会。
Background 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.Methods We 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.Results The rates of agreement among the three coronary-revascularization panels were 95, 94, and 96 percent for inappropriate-use scenarios and 93, 92, and 92 percent for necessary-use scenarios. Agreement among the three hysterectomy panels was 88, 70, and 74 percent for inappropriate-use scenarios. Scenarios involving necessary use of hysterectomy were not assessed. The three-way kappa statistic to detect overuse was 0.52 for coronary revascularization and 0.51 for hysterectomy. The three-way kappa statistic to detect underuse of coronary revascularization was 0.83. Application of individual panels' criteria to real populations of patients resulted in a 100 percent variation in the proportion of cases classified as inappropriate and a 20 percent variation in the proportion of cases classified as necessary.Conclusions 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. (N Engl J Med 1998; 338:1888-95.) (C) 1998, Massachusetts Medical Society.