Assessing the appropriateness of care--its time has come.

HEALTH CARE REFORM IN THE UNITED STATES IS likely to fail without fundamental changes in the practice of medicine. What can be done within a year to substantially increase the likelihood that Americans receive appropriate, humane, affordable care? A starting point is to draw on more than 2 decades of empirical research based on the RAND/University of California Los Angeles (UCLA) Appropriateness Method (RUAM) to develop explicit criteria for determining the appropriateness of care. Physicians and patients can use the results from applying this method to make better informed decisions about expensive, elective procedures or diagnostic tests, and the process of developing the criteria will strengthen the clinical evidence base. The RUAM was developed more than 20 years ago in an effort to understand why quality of care in the United States, and in other developed countries, varied so substantially. The method uses a structured process for integrating findings from the scientific literature with clinical judgment to produce explicit criteria for determining the appropriateness of specific procedures. The criteria are used to determine if care is necessary (the care produces substantially more health benefit than harm and is preferred over other available options), appropriate (produces more good than harm by a sufficiently wide margin to justify the use of the procedure), equivocal (potential health benefits and harms are about equal), or inappropriate (health risks are likely to exceed health benefits). The RUAM has been used in research studies around the world, including England, Canada, Switzerland, the Netherlands, and Israel. This approach has been used to judge the appropriateness of a wide range of procedures, including bariatric surgery, coronary artery bypass graft surgery, angioplasty, colonoscopy, endoscopy, hysterectomy, prostatectomy, and tympanostomy, and has identified a large proportion of care as not necessary or appropriate (in some cases 50%). The RUAM also has been used to identify underuse, patients for whom the procedure is necessary but to whom the procedure has not been offered by their physician. The goal of this work was not just to produce research results; it was intended to alter the way medicine is practiced. However, the only major nonresearch users became the insurance industry, which was looking for an evidencebased method to review appropriateness, but having industry review appropriateness alienated physicians because they felt their clinical autonomy and judgment were threatened. Times have changed and medical leaders are calling for greater accountability, especially in appropriateness of care. Using the existing appropriateness method as a foundation, the medical profession could begin guaranteeing Americans that an explicit assessment of appropriateness would be performed for at least 50 expensive, elective procedures or diagnostic tests, and that both patients and physicians would be an integral part of that process. How might such a system work? The 50 sets of appropriateness criteria could be established on a national basis by 5 to 10 nonprofit organizations that have the requisite expertise, all using the RUAM. Doing this, and making associated improvements as the science of quality assessment evolves, would require about $100 million per year, most likely from federal sources. A coordinating center could ensure the consistency, quality, and timeliness of the work across these organizations. The initiative could also develop Web-accessible forms to produce appropriateness ratings for individual patients by following 8 steps: (1) select a procedure; (2) perform a literature review that includes information about use, efficacy, effectiveness, benefit, and risk for specific subgroups of patients; (3) develop an exhaustive and comprehensive set of clinical scenarios that describe both appropriate and inappropriate use of the procedure (scenarios may vary from 100 to 2000 per procedure); (4) select a multidisciplinary panel of 9 physicians to rate scenarios, after they read the literature review, on a scale of 1 to 9 (physicians who do not perform the procedure comprise a majority of the panel); (5) convene panel to discuss, modify, and rate the scenarios; (6) develop an efficient Web-based form that quickly but reliably allows the patient and physician to work together to determine the appropriateness score that is applicable to the specific patient; (7) use score to decide what to do next; and (8) con-