Hysterectomy, HMOs, and Appropriateness

Abstract

To the Editor. —Several aspects of the study by Bernstein et al 1 deserve further discussion. In the absence of longitudinal, outcomes-based studies defining which patients benefit from a given intervention, efforts to determine appropriateness of care must rely on the use of expert opinion. Attempts to model the decision-making process of experts and incorporate expert opinion into a series of portable algorithms represent a major advancement in the development of appropriateness criteria. However, it is important to bear in mind the limitations inherent in this approach. Depending on the quality and quantity of scientific information available to them, experts frequently disagree, and even when they agree, experts can be wrong. Despite obvious weaknesses, the current criterion standard for appropriateness determinations is individual case review by experts in the same field. The design of the study by Bernstein et al assumes that the RAND protocols alone, without subsequent peer review