Rate Of Inappropriate Use Research Articles

Evaluation and economic impact analysis of different treatment options for ankle distortions in occupational accidents

Appropriate use of diagnostic and treatment modalities are essential for rational use of resources. The aim of this study is to evaluate the use of diagnostic modalities and different treatment options and their economic impacts following an acute ankle distortion resulting from an occupational accident. We evaluated the type-of-treatment impact on the victims' course of recovery as well as its impact on the associated accident costs. Research was carried out in Belgium. An ankle distortion victims' database consisting of 200 cases of (Belgian) occupational accidents during the period 2005-2007 was analysed. Patients who were prescribed immobilization or the use of adjuvant support or physical therapy (118 cases) were not employed during a period of 37 days on average, with a mean total cost of 3140.14 Euros caused by the ankle sprain. Patients without any adjuvant therapy (82 cases) were characterized by an unemployment rate of 15 days on average, and a total cost of 1077.86 Euros. Cast immobilization, although its application is not supported by evidence-based literature, was still applied in 36% of the population studied and resulted in the longest average absence of work of 42 days with an obvious significant increase in medical and total costs. Our results show a high rate of inappropriate use of cast immobilizations for ankle distortions. From an economic point of view and for the same clinical endpoint (being full resumption of the occupational activities), simple conventional treatment, consisting of rest, ice, compression and elevation at diagnosis with allowance of early weight bearing in the further clinical course, leads to the quickest full resumption of activities in combination with the lowest medical costs, if compared with any other kind of treatment.

The Internal Diameter of the Radius and Ulna in Korean Children

Purpose: Flexible intramedullary nailing is a advanced method for treating forearm fractures with fewer complications. But sometimes these nails should not be used due to the narrower internal diameter of the forearm bones. We studied the inner diameter of the radius and ulna of children along with their age in relation to the width of the nail. Materials and Methods: We reviewed the forearm AP radiographs of all the patients who visited our institute during a specific period, in which their age was between 6 and 19. We measured the inner diameters of the radius and ulna at their narrowest location, and we analyzed the diameter in relation to the patients’ age groups, and we compared this data with the width for the nail. Results: A total of 208 patients was included in this study. The inner diameter grew with their increasing age, and the younger the patients, the higher was the rate of inappropriate use of the nail. On linear regression analysis, the age plus or minus 1 SD for usage of the ready-made nail was 12.6 years-old for the male radius. Conclusion: The nail was sometimes too thick for the diameter of the forearm bones of Korean children. It is correct for the surgeon to select whatever material to fix the fracture, but appropriate thickness of the nail should be selected thoughtfully in preoperative planning.

The rate of inappropriate use of IV proton pump inhibitors in the hospital setting is high,

The rate of inappropriate use of IV proton pump inhibitors in the hospital setting is high,

Appropriateness of glycopeptide use in a hospital in Italy

The aims of this study were to quantify the rate of inappropriate glycopeptide use. The study was carried out by reviewing all medical records of patients who received a glycopeptide in a hospital located in Italy. A total of 452 patients received glycopeptides, with a rate of inappropriate use of 90.9%. Appropriateness of glycopeptide prescriptions was significantly higher in Intensive Care Units compared with surgical wards (odds ratio (OR) = 0.03; 95% confidence interval (CI) = 0.01–0.14), in younger patients (OR = 0.97; 95% CI = 0.95–0.99) and in those patients who received the prescription for therapy rather than prophylaxis (OR = 0.2; 95% CI = 0.06–0.66). Models were also developed to predict appropriateness of glycopeptide indications for therapy and prophylaxis. The information obtained in our audit may enable development of strategies to improve physician prescribing patterns.

Using a clinical pathway and education to reduce inappropriate prescribing of enoxaparin in patients with acute coronary syndromes: a controlled study

To evaluate efficacy of a pathway-based quality improvement intervention on appropriate prescribing of the low molecular weight heparin, enoxaparin, in patients with varying risk categories of acute coronary syndrome (ACS). Rates of enoxaparin use retrospectively evaluated before and after pathway implementation at an intervention hospital were compared to concurrent control patients at a control hospital; both were community hospitals in south-east Queensland. The study population was a group of randomly selected patients (n = 439) admitted to study hospitals with a discharge diagnosis of chest pain, angina, or myocardial infarction, and stratified into high, intermediate, low-risk ACS or non-cardiac chest pain: 146 intervention patients (September-November 2003), 147 historical controls (August-December 2001) at the intervention hospital; 146 concurrent controls (September-November 2003) at the control hospital. Interventions were active implementation of a user-modified clinical pathway coupled with an iterative education programme to medical staff versus passive distribution of a similar pathway without user modification or targeted education. Outcome measures were rates of appropriate enoxaparin use in high-risk ACS patients and rates of inappropriate use in intermediate and low-risk patients. Appropriate use of enoxaparin in high-risk ACS patients was above 90% in all patient groups. Inappropriate use of enoxaparin was significantly reduced as a result of pathway use in intermediate risk (9% intervention patients vs 75% historical controls vs 45% concurrent controls) and low-risk patients (9% vs 62% vs 41%; P < 0.001 for all comparisons). Pathway use was associated with a 3.5-fold (95% CI: 1.3-9.1; P = 0.012) increase in appropriate use of enoxaparin across all patient groups. Active implementation of an acute chest pain pathway combined with continuous education reduced inappropriate use of enoxaparin in patients presenting with intermediate or low-risk ACS.

Prevention of Nosocomial Catheter-Associated Urinary Tract Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol

Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection. The authors' baseline rate of CAUTI for general medical service was elevated at 36 per 1000 catheter-days. The medical literature has consistently linked inappropriate catheter use with the development of CAUTI. The baseline data also revealed a high rate of inappropriate use of indwelling urinary catheters. Using the dual modalities of technology through prompts in the computerized order/entry system and handheld bladder scanners, as well as in combination with staff education and nurse empowerment, the authors were successful in reducing the use and duration of urinary catheters as well as the incidence of CAUTI. In subsequent data collection cycles over the following 2 years, 81% reduction in device use and a 73% reduction in the clinical end point of nosocomial CAUTI (36/1000 catheter-days to 11/1000 catheter-days; P < .001) was demonstrated.

ELISA D-DIMER MEASUREMENT FOR THE CLINICAL SUSPICION OF PULMONARY EMBOLISM IN THE EMERGENCY DEPARTMENT: ONE-YEAR OBSERVATIONAL STUDY OF THE SAFETY PROFILE AND PHYSICIAN’S PRESCRIPTION.

Objectives: to validate the safety profile of a rapid ELISA D-dimer as the first diagnostic step in the clinical suspicion of pulmonary embolism (PE) in outpatients admitted to an emergency department (ED), and to retrospectively evaluate the appropriateness of the physician’s prescription.Design and setting: an observational study of all patients admitted to the ED of an urban university teaching hospital with signs and symptoms justifying the prescription of a rapid ELISA D-dimer measurement (Vidas; Biomerieux; France) as the first line diagnostic test for PE. Acute PE was established or excluded according to an appropriate combination of the D-dimer concentration, the lung scintigraphy, the spiral computerized tomography (spiral CT), the venous ultrasonography, and the arteriography in case of uncertain results. All patients with D-dimer values under the cut-off point of 500 ng/ml were followed up after 6 months.Results: 395 patients were studied. A normal D-dimer concentration < 500 ng/ml was found in 179 patients (45% of the cohort). The retrospective analysis showed that none of these patients were found to have a high pre-test clinical probability. None of these 179 patients received anticoagulation nor displayed a PE event during a 6-month period (negative predictive value 100%; 95%CI, 98.0 to 100%; sensitivity 100%; 95% CI, 90.3 to 100%). Among the 216 patients (55%) with D-dimer values above 500 ng/ml, PE was confirmed in 32 cases, for a prevalence of the disease of 8,1%. Eighty-six patients (22%) had no additional testing in spite of positive D dimer values > 500 ng/ml, pointing out a 22% rate of inappropriate use of the D-dimer measurement.Conclusion: this observational study confirms that a normal rapid ELISA D-dimer value (< 500 ng/ml) used as a first diagnostic step in ruling out the diagnosis of PE is a safe clinical practice when the pre-test clinical probability is low or intermediate. Nevertheless, the low prevalence rate of the disease (8,1%) suggests a potential overused and inappropriate prescription.

Effectiveness of pharmacy policies designed to limit inappropriate vancomycin use: a population-based assessment.

In Oregon in 1994, a population-based study of 66 nonpsychiatric hospitals indicated that 40% of vancomycin orders were inappropriate according to Centers for Disease Control and Prevention guidelines. We repeated the study to determine whether vancomycin use had been affected by pharmacy policies implemented following the 1994 study. We surveyed pharmacists in nonpsychiatric hospitals in Oregon regarding vancomycin use policies in their hospitals. Using pharmacy records, we identified and abstracted the charts of all patients in Oregon hospitals receiving vancomycin during a 3-week period to determine appropriate use of vancomycin. Thirteen (20%) of 64 hospitals had implemented a vancomycin restriction policy since 1994; none ofthe remaining hospitals in the study had a policy. In 1999, hospitals with vancomycin restriction policies had substantially decreased rates of inappropriate vancomycin use compared with hospitals without such policies (1.0 vs 1.8 orders per 1,000 patient-days; P = .01). Compared with 1994 baseline rates of inappropriate use, hospitals that adopted policies experienced a decrease (from 1.5 orders per 1,000 patient-days in 1994 to 1.0 in 1999; P= .13), whereas hospitals without policies experienced a statistically significant increase (from 0.9 orders per 1,000 patient-days in 1994 to 1.8 in 1999; P= .001). Restriction policies were most effective at reducing rates of inappropriate use for treatment of confirmed gram-positive infections and prophylaxis. Vancomycin restriction policies were associated with a decrease in inappropriate therapeutic and prophylactic vancomycin use, but had no effect on inappropriate empiric use. Hospitals considering limits regarding inappropriate use should consider implementation of institution-based vancomycin restriction policies as part of an overall strategy.

Prescription medication use among an aboriginal population accessing addiction treatment.

Inappropriate prescription medication use can have significant consequences. Although it is suspected that Aboriginal populations within Canada have high rates of inappropriate use, published information is lacking. To better understand this issue, we studied an Aboriginal population seeking addiction treatment. We surveyed Aboriginal clients who accessed addiction treatment in Calgary, Alberta, for prescription medication use in the previous year, frequency of medication use, and medication source(s), if inappropriately used. Sixty-nine percent of the clients completed the survey (n = 144). Most respondents were aged 31 to 50 years (56%), and 52% were male. Of the respondents, 48% reported that they used prescription medication inappropriately, 8% indicated appropriate use, and the rest indicated no medication use. Sedatives or relaxants were most frequently used inappropriately. Among those who inappropriately used medication, 47% used medication more than 10 times in the previous year. Common sources for those who used medication inappropriately included medication given by a friend or a stranger (52%), medication bought on the street (45%), and medication prescribed by a physician (41%). Age greater than or equal to 30 years was associated with inappropriate use. Sex, residence, and Aboriginal status were not found to be associated with inappropriate use. Inappropriate prescription medication use was a significant problem among an Aboriginal population that sought addiction treatment, and many of these individuals accessed medication from a prescribing physician.

Diagnostic yield of open access colonoscopy according to appropriateness

Background: Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. Evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this study was to assess the appropriate use of colonoscopy in an open-access system and to establish the yield of diagnostic information relevant to patient care. Methods: Overall, 1123 consecutive patients referred for open-access colonoscopy were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between the appropriate use of colonoscopy and the presence of relevant endoscopic findings. Results: The rate of colonoscopies “generally not indicated” according to ASGE guidelines was 29% (39% for primary care physicians and 23% for specialists; p < 0.0001). A relevant endoscopic finding was detected in 338 examinations (35%). The diagnostic yield was significantly higher for “generally indicated” colonoscopies (43%) compared with “generally not indicated” procedures (16%) ( p < 0.001). Conclusions: Although the rate of inappropriate use of colonoscopy was high, open-access colonoscopy was effective in detecting neoplastic lesions. Because most of these were detected during examinations performed for appropriate indications, the appropriateness of the indication emerges as crucial to the cost-effectiveness of an open-access system. (Gastrointest Endosc 2001;54:175-9.)

Diagnostic yield of open access colonoscopy according to appropriateness☆, ☆☆

<h2>Abstract</h2> <b>Background:</b> Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. Evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this study was to assess the appropriate use of colonoscopy in an open-access system and to establish the yield of diagnostic information relevant to patient care. <b>Methods:</b> Overall, 1123 consecutive patients referred for open-access colonoscopy were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between the appropriate use of colonoscopy and the presence of relevant endoscopic findings. <b>Results:</b> The rate of colonoscopies "generally not indicated" according to ASGE guidelines was 29% (39% for primary care physicians and 23% for specialists; <i>p</i> < 0.0001). A relevant endoscopic finding was detected in 338 examinations (35%). The diagnostic yield was significantly higher for "generally indicated" colonoscopies (43%) compared with "generally not indicated" procedures (16%) (<i>p</i> < 0.001). <b>Conclusions:</b> Although the rate of inappropriate use of colonoscopy was high, open-access colonoscopy was effective in detecting neoplastic lesions. Because most of these were detected during examinations performed for appropriate indications, the appropriateness of the indication emerges as crucial to the cost-effectiveness of an open-access system. (Gastrointest Endosc 2001;54:175-9.)

Measuring appropriate use of acute beds: A systematic review of methods and results

A systematic review of the methods used to assess appropriateness of acute bed use and the evidence on the scale of inappropriate use in different patient groups is presented. Issues of generalisability of the findings are also addressed. Criteria based tools are the accepted way of measuring inappropriate days of stay and admissions, although opinion based classification is very common. While a number of tools exist, few have been adequately tested for reliability and validity. The Appropriateness Evaluation Protocol (AEP) is the most commonly used tool, and has been tested more widely. It appears to be both reliable and valid. An estimated 29% of admissions to acute psychiatric may be inappropriate. Regarding days of care after admission, between 24 and 58% of stays were not judged to be appropriate for continued stay on an acute ward. The need for continued acute psychiatric care may become lower as patients experience continued stay in the acute setting. A lack of housing and community support was the most commonly cited reason preventing discharge. Rates of inappropriate use appear to be higher for older patients than for the general population. Wide variation in rates of inappropriate days of stay was found, but it may be safe to assume that inappropriate use is greater than 20% across a wide variety of settings. Reasons for older patients to remain in an acute hospital bed after medically necessary are typically moderate nursing care needs (i.e. long-term care). The estimates of inappropriate use in other groups was found to be highly variable. Before definitive conclusions on the inappropriate use of acute beds can be made, future research needs to take into account the methodological problems discussed here.

Determinants of vancomycin use in adult intensive care units in 41 United States hospitals.

We analyzed data from a prospective observational cohort study that included 108 adult intensive care units (ICUs) in 41 United States hospitals. Use of vancomycin (defined daily doses per 1,000 patient-days), nosocomial infection rates, and proportion of all Staphylococcus aureus isolates resistant to methicillin (MRSA rate) were recorded from January 1996 through November 1997. The median rate of vancomycin use was lowest in coronary care ICUs and highest in general surgical ICUs. Prior approval before use of vancomycin was required in only 26 (24%) of the 108 ICUs. In a multivariate linear regression model, rates of MRSA, central line-associated bloodstream infection, and the type of ICU were independent predictors of vancomycin use. None of the vancomycin control practices was associated with lower rates of vancomycin use; however, it is important to recognize that this database was not designed to measure rates of inappropriate use. Vancomycin use is heavily determined by rates of endemic MRSA and central line-associated bloodstream infection. Efforts to reduce these rates through infection control activities should be included in hospitals' efforts to reduce vancomycin use.

Inappropriate use of the ambulance service

To determine the rate of inappropriate use of the ambulance service a prospective study of patients brought to a Dublin accident and emergency (A&E) department by ambulance was performed over a 78-day period--358 cases were analysed representing 37% of the ambulance case load. The receiving A&E physician deemed 43.3% of cases to have a definite indication for calling an ambulance, 36.9% a relative indication and 19.8% to have no indication. A strong correlation was shown between a definite indication for transport by ambulance and admission to hospital. Acute medical illness was the most common presentation in the study group (45.8%). Patients themselves were predominant in calling for a 999 ambulance and 35.8% were deemed to have no indication for doing so. When a general practitioner requests the ambulance only 7.4% of cases had no indication for the action. Approximately one-third (31%) of 999 calls were made because the patient had no transport alternative. The problem of ambulance misuse is multifactorial and a variety of strategies are required to address the issue.

Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study

Background: Prospective data describing the appropriateness of use of colonoscopy based on detailed panel-based clinical criteria are not available. Methods: In a cohort of 553 consecutive patients referred for colonoscopy to two university-based Swiss outpatient clinics, the percentage of patients who underwent colonoscopy for appropriate, equivocal, and inappropriate indications and the relationship between appropriateness of use and the presence of relevant endoscopic lesions was prospectively assessed. This assessment was based on criteria of the American Society for Gastrointestinal Endoscopy and explicit American and Swiss criteria developed in 1994 by a formal panel process using the RAND/UCLA appropriateness method. Results: The procedures were rated appropriate or equivocal in 72.2% by criteria of the American Society for Gastrointestinal Endoscopy, in 68.5% by explicit American criteria, and in 74.4% by explicit Swiss criteria (not statistically significant, NS). Inappropriate use (overuse) of colonoscopy was found in 27.8%, 31.5%, and 25.6%, respectively (NS). The proportion of appropriate procedures was higher with increasing age. Almost all reasons for using colonoscopy could be assessed by the two explicit criteria sets, whereas 28.4% of reasons for using colonoscopy could not be evaluated by the criteria of the American Society for Gastrointestinal Endoscopy ( p < 0.0001). The probability of finding a relevant endoscopic lesion was distinctly higher in the procedures rated appropriate or equivocal than in procedures judged inappropriate. Conclusions: The rate of inappropriate use of colonoscopy is substantial in Switzerland. Explicit criteria allow assessment of almost all indications encountered in clinical practice. In this study, all sets of appropriateness criteria significantly enhanced the probability of finding a relevant endoscopic lesion during colonoscopy. (Gastrointest Endosc 1998;48:128-36.)

Comparison of the appropriateness of coronary angiography and coronary artery bypass graft surgery between Canada and New York State

<h3>Objective.</h3> —To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. <h3>Design.</h3> —Retrospective randomized medical record review. <h3>Setting.</h3> —All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. <h3>Patients.</h3> —All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. <h3>Main Outcome Measures.</h3> —Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. <h3>Results.</h3> —For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%;<i>P</i>&lt;.001) and CABG (6% vs 14%;<i>P</i>&lt;.001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%;<i>P</i>=.023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (<i>P</i>&lt;.0001). <h3>Conclusions.</h3> —Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination. (<i>JAMA</i>. 1994;272:934-940)

Comparison of the Appropriateness of Coronary Angiography and Coronary Artery Bypass Graft Surgery Between Canada and New York State

To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. Retrospective randomized medical record review. All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%; P < .001) and CABG (6% vs 14%; P < .001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%; P = .023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (P < .0001). Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination.

The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium

To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. Retrospective cohort study. Seven managed care organizations. Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees.

The Appropriateness of Use of Coronary Artery Bypass Graft Surgery in New York State

To determine the appropriateness of use of coronary artery bypass graft surgery in New York State. Retrospective randomized medical record review. Fifteen randomly selected hospitals in New York State that provide coronary artery bypass graft surgery. Random sample of 1338 patients undergoing isolated coronary artery bypass graft surgery in New York State in 1990. Percentage of patients who had bypass surgery for appropriate, inappropriate, or uncertain indications; operative (30-day) mortality; and complications. Nearly 91% of the bypass operations were rated appropriate; 7%, uncertain; and 2.4%, inappropriate. This low inappropriate rate differs substantially from the 14% rate found in a previous study of patients operated on in 1979, 1980, and 1982. The difference in rates was not due to more lenient criteria but to changes in practice, the most important being that the fraction of patients receiving coronary artery bypass grafts for one- and two-vessel disease fell from 51% to 24%. Individual hospital rates of inappropriateness (0% to 5%) did not vary significantly. Rates of appropriateness also did not vary by hospital location, volume, or teaching status. Operative mortality was 2.0%; 17% of patients suffered a complication. Complication rates varied significantly among hospitals (P < .01) and were higher in downstate hospitals. The rates of inappropriate and uncertain use of coronary artery bypass graft surgery in New York State were very low. Rates of inappropriate use did not vary significantly among hospitals, or according to region, volume of bypass operations performed, or teaching status.

The Appropriateness of Hysterectomy

Objective. —To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. Design. —Retrospective cohort study. Setting. —Seven managed care organizations. Patients. —Random sample of all nonemergency, nononcological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. Main Outcome Measures. —Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. Results. —Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. Conclusion. —The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees. ( JAMA . 1993;269:2398-2402)