The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures

Lawson, Elise H.; Gibbons, Melinda M.; Ko, Clifford Y.; Shekelle, Paul G

doi:10.1016/j.jclinepi.2012.07.002

Cited by 82 publications

(66 citation statements)

References 56 publications

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“…3). This is deviant from other RUAM studies that have shown a significant impact of panellist discipline on the ratings [30]. Furthermore, the appropriateness outcomes tended to be highly specific as in 48 and 87% of scenarios exclusively one or maximally two treatments were considered appropriate.…”

Section: Discussioncontrasting

confidence: 89%

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The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method

et al. 2018

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Section: Discussioncontrasting

confidence: 89%

“…The RUAM consists of a structured and iterative process of individual (independent and anonymous) rating rounds and plenary discussion meetings. Results of various methodological and outcome studies support the reliability, internal consistency, and clinical validity of the RUAM [30][31][32][33][34][35].…”

Section: Methodsmentioning

confidence: 77%

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method

et al. 2018

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“…Encouraging access to patients who have the most pressing need for surgery, and who are most likely to benefit, while limiting it for those who do not, would ideally contain costs while optimizing overall outcomes. Evidence-based appropriateness criteria (AC) are effective tools to measure underuse and overuse of elective procedures (4). A number of AC for TKR exist, yet none have been developed for US patients (1).…”

Section: Introductionmentioning

confidence: 99%

Evaluation of Two Appropriateness Criteria for Total Knee Replacement

Ghomrawi

Alexiades

Pavlov

et al. 2014

Arthritis Care & Research

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Objective. Insurance expansion under the Affordable Care Act will amplify a projected 6-fold increase in total knee replacement (TKR) utilization by 2030 but will not fully address TKR disparities. Promoting appropriate use of TKR would help reduce disparities and improve outcomes. There are currently no validated appropriateness criteria (AC) for TKR in the US. We evaluated the performance of 2 non-US AC in a cohort of US TKR patients. Methods. AC1 was developed in Spain using the modified Delphi method with 624 patient scenarios. AC2 was developed in Canada using the overall Western Ontario and McMaster Universities Osteoarthritis Index score of >39 as the cutoff point for surgery. These criteria were applied to a random sample of TKR patients enrolled in our institutional registry. Preoperative clinical, radiographic, and patient-reported survey data were used in classifying patients. The rate of appropriateness was compared for the 2 AC. Inappropriate cases were further investigated to determine other mitigating factors beyond the criteria influencing the decision to operate. Results. In total, 508 TKR procedures were evaluated. All patients had osteoarthritic radiographic changes. On the basis of AC1, 7.7% of cases were classified as inappropriate and 11.6% uncertain. On the basis of AC2, 31.5% were classified as inappropriate. Only 4.7% of the cases were classified as inappropriate by both ACs; however, there was poor agreement between the 2 AC ( ‫؍‬ ؊0.08). Beyond the criteria, failure of nonsurgical treatment and clinically significant valgus/varus deformities influenced the decision for surgery. Conclusion. There was poor agreement between 2 validated AC for TKR when tested in a US population. Culturally specific AC are needed to promote rational use of TKR.

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“…The RAM has been extensively validated and used in numerous medical procedures, including coronary angiography, coronary artery bypass graft surgery, carotid endarterectomy, abdominal aortic aneurysm surgery, and bariatric surgery. 9–14 The purpose of this study was to develop appropriateness criteria to help select the most appropriate type of hemodialysis vascular access creation for individual patients.…”

mentioning

confidence: 99%

Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure

Woo

Ulloa

Allon

et al. 2017

Journal of Vascular Surgery

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Objective The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. Methods The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists’ scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. Results Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon’s decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. Conclusions The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.

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The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures

Cited by 82 publications

References 56 publications

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method

Evaluation of Two Appropriateness Criteria for Total Knee Replacement

Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure

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