Abstracts » Health

Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography

Article Abstract:

Research results from a previous study indicated that certain medical procedures performed on Medicare patients are carried out inappropriately, where ''appropriate'' procedures were those whose health benefits exceeded their health risks. Thus, 17 percent of coronary angiographic procedures (visualization of the coronary arteries, which supply blood to the heart, with X-ray), 17 percent of endoscopies of the upper gastrointestinal tract (viewing the upper digestive tract with a bright light and magnifying lens) and 32 percent of carotid endarterectomies (in which the lining of the carotid artery, which carries blood to the head, is cleaned of its plaque and fatty deposits), were inappropriately performed (overused). However, the earlier study did not investigate how overuse can be predicted: for instance, are certain physicians, patients, or hospitals likely to be more culpable in this regard? This was addressed by analyzing the data from the original study, which included 4,564 Medicare patients 65 or older who lived in one of five states and underwent one of the three procedures. Several characteristics of patients (income level, race, age, sex), physicians (volume of procedures, age, board certification, foreign degree) and hospitals (teaching, public, nonprofit, occupancy) were investigated to see whether correlations could be found between any such characteristics and the degree of overuse. Results include a vast array of information regarding all these factors; few, however, accounted for the variability in appropriateness. For coronary angiography, older people with higher incomes had the greatest risk of undergoing a medically appropriate procedure. Appropriate procedures in all three cases were most likely in teaching hospitals, especially for carotid endarterectomy. Patients treated by surgeons who performed a high volume of procedures had a higher chance of undergoing an inappropriate one, but no other physician characteristic consistently affected patients' chances for inappropriate procedures. Predicting the appropriateness of care is not a simple process; however, the issue needs to be addressed systematically if health care in the US is to improve. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Causes of, Angiography

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Does inappropriate use explain small-area variations in the use of health care services?

Article Abstract:

Studies have shown that the use of various medical procedures differs substantially by geographic region. Researchers have been unable to explain why a procedure may be utilized more frequently in certain localities, but one possible reason is that physicians are using the procedure inappropriately. Inappropriate use is defined as use in a patient who cannot reasonably be expected to benefit, and may even be harmed by the procedure. The appropriateness of three procedures was evaluated in 23 adjacent counties of one state. Small geographic areas were compared because studies of larger regions had not shown differences in appropriateness of use. The medical procedures evaluated were coronary angioplasty (dilating a coronary artery to improve blood flow), carotid endarterectomy (surgery to remove blockage from the carotid artery), and upper gastrointestinal tract endoscopy (insertion of a tube into the stomach to view its lining). Criteria for appropriate use of these procedures were set in advance by experts, and the medical records of Medicare patients were then reviewed. The rate of inappropriate use varied among counties, but little of the variation in how often the procedures were performed could be explained by inappropriate use. A distinction must be made between areas that use a procedure often but appropriately and regions that may use it rarely but inappropriately. In this era of medical cost containment, overuse must be clearly defined as inappropriate use, and only these cases should be eliminated. The number of procedures performed should not be reduced if all the patients genuinely stand to benefit. (Consumer Summary produced by Reliance Medical Information, Inc.)

Angioplasty

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Relation between surgeons' practice volumes and geographic variation in the rate of carotid endarterectomy

Article Abstract:

Geographic variations in the rates of medical procedures are used as a means of identifying appropriate performance of medical services by doctors in different areas. Computer analysis of medical databases assumes that rates above the norm indicate inappropriate use of services. However, the Rand/University of California at Los Angeles (UCLA) Health Services Utilization Study does not support this widespread belief. A comparison of surgeons' practice volumes and the geographic variations in the rate of carotid endarterectomy operations (removal of the damaged lining of the carotid artery) was conducted in areas of high, average and low use of the procedure in 1981. Regional differences in the rates of carotid endarterectomy were attributed to a small number of physicians in high-use areas who perform large numbers of the operation. By studying the proliferation of carotid endarterectomies, researchers were able to develop a better understanding of how a technology is adopted and how the referral process works among both patients and physicians. These surgeons were not abusing the use of this operation, rather, they were deemed most competent in terms of the demands of successfully performing carotid endarterectomy. The researchers suggest that the same type of study should be repeated for other operations and procedures.

Case studies, Practice, Demographic aspects, Surgery, Surgeons, Medicare

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