| Procedure | % inappropriate | % uncertain | Source of population | # of patients evaluated |
|---|---|---|---|---|
| Carotid Endarterectomy 1 | 18% (51/281) overall; neurosurgery 14% vs. non-neurosurgery 21%; varied from 0% to 33% among surgeons (P = 0.07) | 49% (138/281) overall, decreased to 45% after adjusting for benefit of CEA for severe symptomatic disease found in NASCET; 40% neurosurgery vs. 55% non-neurosurgery; varied from 33% to 67% across surgeons (P=.26) | All in Edmonton, Alberta, Canada | 291 cases of CEA performed on 265 patients between April 1994 and Sept 1995, from nine surgeons at four teaching hospitals (2 were tertiary-care centers); excluded patients without angiograms (10) |
| Carotid Endartectomy 24 *follow up to above study | 4% (8/184) | 47% (84/184) | All in Edmonton, Alberta, Canada | 184 patients with CEA between 9/1/96 and 8/31/97 were evaluated after results of previous study, CEA guidelines and notification of possible surveillance were distributed to all surgeons performing CEA in Edmonton |
| Carotid Endarterectomy 2 | Definition A (low risk of stroke/death):~55% Definition B: ~5% Definition C:~5% | Definition A (low risk of stroke/death): ~12% Definition B: ~37% Definition C:~14% | Twelve academic medical centers | 1160 randomly selected patients with CEA from 1988-1990 (with the exception of one hospital which included 1987 data), miscoded charts were excluded |
| Carotid Endarterectomy 3 | 32% overall; varied from 29% to 40% among sites | 32% overall; varied from 29% to 34% among sites | 5 sites of varying utilization for the 3 procedures selected from Medicare claims submitted by physicians in Arkansas, Colorado, Iowa, Mass., Montana, Penn., S. Carolina, and N. Calif. | Random sample of Medicare beneficiaries for each procedure (claims submitted in 1981) at each site (high, average, and low use geographic areas) |
| Carotid Endarterectomy 4 | Varied by county from 0% - 67% | No discussion of equivocal indication | 23 adjacent rural and urban, large and small, counties in one large, populous state | Sampled procedures by Medicare billing codes performed on 600 CEA patients in 1981, aged 65 years and older |
| Carotid Endarterectomy 22 | 3.9% characterized as inappropriate; study considered CEA inappropriate if the case was "uncertain" or "proven inappropriate". | 1993 Medicare admissions in Georgia w/procedure code for CEA | 1945 CEAs performed on Medicare recipients in GA in 1993 | |
| Cataract Surgery 5 | 2% (15/723) overall; varied from 0% to 6% by institution | 8% (359/723) overall; varied from 0% to 15% by institution | Ten Academic Medical Centers | 1139 randomly selected until approx. 130 patients at each facility w/cataract surgery in 1990 were obtained; patients receiving other ocular surgery performed at the same time as cataract surgery or with specific ICD-9 CM or CPT-4 were excluded |
| Cholecystectomy 6 | 12% overall; varied from 6%-14% (p=.002) among hospitals | 17% overall; varied from 9%-24% (p=.002) among hospitals | Four Israeli hospitals belonging to the General Sick Fund (provides prepaid healthcare to 76% of Israeli population) | 816 patients identified as having undergone cholecystectomy in 1986; 702 records were located and evaluated; complete clinical info was obtained on 657 patients |
| Colonoscopy 7 | 27.8% (110/553) by ASGE criteria; 31.5% (170/553) by US 94 criteria; 25.6% (138/553) by Swiss 94 criteria | No rating for ASGE; 10.9% (59/553) by US 94 criteria; 11.6% (63/553) by Swiss 94 criteria | Two university-based multi-specialty outpatient clinics in Lausanne and Basel, Switzerland | 553 consecutive patients referred by the outpatient clinics for colonoscopy, aged >15 from January 1995 to September 1995 (Lausanne) and January 1995 to July 1995 (Basel) |
| Coronary Angiography 26 | 7% (1/14) of blacks; 10% (4/41) whites who underwent angiography | 50% (7/14) of blacks; 46.3% (19/41) whites who underwent angiography | Department of Veterans Affairs | 200 (100 white and 100 black) VA inpatients discharged between 1/193 and 12/1/93 with primary dx of cardiovascular disease or chest pain |
| Coronary Angiography 8 | 6% overall; no difference across subgroups | 16% overall; no difference across subgroups | Harvard Community Health Plan (HCHP), Brookline Mass; mixed model HMO | 292 HCHP enrollees with coronary angiography in 1992; stratified into four subgroups |
| Coronary Angiography 9 | 21% overall | 30% overall | Trent region; coronary angiography is done in 3 referral centers and CABG in 2 centers. | random sample of 320 patients with coronary angiography between 2/1/87 and 5/30/88. Exclusions: incomplete records, congenital heart disease, transplant, primary valve disease. |
| Coronary Angiography 3 | 17% overall; varied from 15%-18% among sites | 9% overall; varied from 4%-10% among sites | 5 sites of varying utilization for the 3 procedures selected from Medicare claims submitted by physicians in Arkansas, Colorado, Iowa, Mass., Montana, Penn., S. Carolina, and N. Calif. | Random sample of Medicare beneficiaries for each procedure (claims submitted in 1981) at each site (high, average, and low use geographic areas) |
| Coronary Angiography 4 | Varied by county from 8%-75% | no discussion of equivocal indication | 23 adjacent rural and urban, large and small, counties in one large, populous state | Sampled procedures by Medicare billing codes performed on 600 CA patients in 1981, aged 65 years and older |
| Coronary Angiography 10 |
Canadian Criteria Canadian sample: 9.0% (95% CI, 6.6%-11.4%) New York sample: 10.2% (95% CI, 8.5%-11.8%) US Criteria Canadian sample: 5.1% (95% CI, 3.2%-6.9%) New York sample: 4.2% (95% CI, 3.4%-6.9%) |
Canadian Criteria Canadian sample: 33.2% (95% CI, 29.2%-37.2%) New York sample: 39.1 (95% CI, 35.1%-43.1%) US Criteria Canadian sample: 18.2% (95% CI, 14.9%-21.5%) New York sample: 20.1% (95% CI, 18.4%-21.8%) | All hospitals performing CA and CABG in Ontario and British Columbia; 15 randomly selected hospitals that provide CA in New York State; 15 randomly selected hospitals that provide CABG in New York State | 553 randomly selected patients in Canada, 1333 randomly selected patients in New York. New York patients had procedures performed in 1990; Canadian patients had procedures performed between 4/89 and 3/90. Cases performed primarily for valve surgery were excluded |
| Coronary Angiography 11 | 4% overall; varied from 0% - 9% among hospitals (NS) | 20% overall; varied from 13%-31% among hospitals (NS) | 15 randomly selected, non federal hospitals in New York State providing coronary angiography | Random sample of 1335 patients undergoing angiography in New York State in 1990, distributed across the 15 hospitals |
| CABG 12 | 6% (5/85), compared to 1/85 identified by the original panel of NY cardiologists | 12% (10/85), compared to 1/85 identified by the original panel of NY cardiologists | A follow-up to the above study was done using a sub-sample of the patients. A panel of Duke University cardiologists reviewed 308 records for appropriateness | |
| CABG 13 | 1.6% (95% CI, 0.6% - 2.5%) overall; increased to 1.9% when revised by Consortium surgeons. Varied from 0% to 5% across hospitals (P=0.02) (NS) | 7% (95% CI, 5%-8%) overall; did not vary significantly across hospitals | All 12 Academic Medical Center Consortium hospitals | 1156 patients w/CABG surgery in 1990 w/o previous CABG or concurrent valve replacement surgery, randomly selected consecutively until 100 records were obtained from each facility |
| CABG 14 | 2.4% (95% CI, 2% - 3%) overall; varied from 0% to 5% among hospitals (NS) | 7% (95% CI, 5%-9%) overall; varied from 3% to 15% among hospitals (NS) | 15 randomly selected, non federal hospitals in New York State providing CABG surgery | Random sample of 1338 patients undergoing isolated CABG in NY in 1990; those undergoing another major procedure in conjunction with CABG (55) were excluded; records missing critical data (13) were also excluded |
| CABG 9 | 16% overall | 26% overall | Trent region; coronary angiography is done in 3 referral centers and CABG in 2 centers. | 319 randomly selected patients with CABG between 7/1/87 and 6/31/88. Exclusions: incomplete records, congenital heart disease, transplant, primary valve disease |
| CABG 10 |
Canadian Criteria Canadian sample: 3.6% (95% CI, 2.0%-5.1%) New York sample: 5.5% (95% CI, 4.0%-7.1%) US Criteria Canadian sample: 2.5% (95% CI, 1.2%-3.8%) New York sample: 2.4% (95% CI, 1.6%-3.1%) |
Canadian Criteria Canadian sample: 11.3% (95% CI, 8.7%-14.0%) New York sample: 9.9% (95% CI, 8.4%-11.4%) US Criteria Canadian sample: 9.0% (95% CI, 6.6%-11.4%) New York sample: 7.0% (95% CI, 5.1%-9.0%) | All hospitals performing CA and CABG in Ontario and British Columbia; 15 randomly selected hospitals that provide CA in New York; 15 randomly selected hospitals that provide CABG in New York | 556 randomly selected CABG patients in Canada, 1336 randomly selected CABG patients in New York. New York patients had procedures performed in 1990; Canadian patients had procedures performed between 4/89 and 3/90. Cases performed primarily for valve surgery were excluded |
| CABG (referral after Coronary Angiography) 16 | 9.7% overall | 12.3% overall | Seven of eight public Swedish heart centers. (perform 92% of all bypass surgeries in Sweden) | Consecutive series of 2767 patients with coronary angiography between 5/94 and 1/95 who were considered for coronary revascularization |
| CABG 15 |
RAND criteria: 42% ACC/AHA criteria:17% RAS criteria: 46% |
RAND criteria: 17% ACC/AHA criteria:no rating RAS criteria: no rating | An academic medical center cardiac catheterization laboratory and a VA cardiac catheterization lab in Maryland | 153 catheterization patients referred to a either Univ. of Maryland Cardiac Catheterization Lab and/or Baltimore VA Medical Center Cardiac Catheterization Lab with a variety of cardiac diagnoses and treatments between 3/93 and 10/94 |
| PTCA 15 |
RAND criteria: 22% ACC/AHA criteria: 49% RAS criteria: 35% |
RAND criteria: 29% ACC/AHA criteria: no rating RAS criteria: no rating | An academic medical center cardiac catheterization laboratory and a VA cardiac catheterization lab in Maryland | 153 catheterization patients referred to a either Univ. of Maryland Cardiac Catheterization Lab and/or Baltimore VA Medical Center Cardiac Catheterization Lab with a variety of cardiac diagnoses and treatments between 3/93 and 10/94 |
| PTCA (referral after Coronary Angiography) 16 | 38.3% overall | 30.0% overall | Seven of eight public Swedish heart centers. (perform 92% of all bypass surgeries in Sweden) | Consecutive series of 2767 patients with coronary angiography between 5/94 and 1/95 who were considered for coronary revascularization |
| PTCA 12 | 12% (11/95), compared to 9/95 identified by the original panel of NY cardiologists | 27% (26/95), compared to 23/95 identified by the original panel of NY cardiologists | A follow-up to reference 11 was done using a sub-sample of the patients. A panel of Duke University cardiologists reviewed 308 records for appropriateness | |
| Diagnostic testing for Coronary Artery Disease 17 | 3% (7/215) overall | 39% (42/109) overall | Five urban Los Angeles area hospital emergency departments, 2 public, 1 private NFP, 1 university med. ctr., 1 NFP HMO | 356 patients with chest pain not due to myocardial infarction or history of cardiac disease between Oct 94 and Apr 96. Those not receiving ECG during initial eval were excluded |
| Hip Joint Replacement 25 | 8.3% (86/997) overall; 6.7% - 16.3%. for osteoarthritis, 0% - 25.0% for avascular necrosis, 0% for fracture and revision | 32.4% (334/997) overall; 42.3%-50.0% for osteoarthritis, 0%- 50.0% for avascular necrosis, 9.6%-40.0% for fracture, 3.4%-18.9% for revision | 5 large public hospitals (4 university affiliated, 1 community-based) | 997 patients with osteoarthritis, avascular necrosis, hip fracture, or revision who were undergoing HJR between 12/96 and 12/97 |
| Hip and Knee Joint Replacement 21 | High-rate region: 6.1% Low-rate region: 6.4% Rated by subspecialists High-rate region: 11.4% Low-rate region: 11.0% | Not evaluated | 7 high-rate region hospitals: 3 university affiliated, 4 community
8 low-rate region hospitals: 5 university affiliated, 3 community | 371 patients in the high rate region and 565 in the low rate region with surgery performed between 4/1/92 and 3/31/93 without fracture or other indication, and < 60 years old |
| Hysterectomy 18 | 16% overall; varied across plans from 10% to 27% | 25% overall | Seven managed care organizations | Random sample of 642 hysterectomies (non-emergency and non-oncological) between 8/1/89 and 7/31/90, among women enrolled in a health plan 2 years prior to surgery |
| Hysterectomy 23 | 70% (367/497); varied from 45% to 100% across diagnoses indicative of hysterectomy | Not evaluated | Nine capitated medical groups in Southern California | 497 women receiving hysterectomy between 8/93 and 7/95 in one of nine capitated medical groups in S. California |
| Laminectomy 19 | 23% | 29% | One Swiss University hospital | 196 patients with surgical treatment for herniated discs |
| Lumbar Discectomy and Spinal Stenosis surgery 20 | 38% (126/328) | Combined with "appropriate" category | Two university neurosurgery departments | 328 consecutive patients undergoing surgery for Lumbar Disc Hernia of Spinal Stenosis at hosp A from 4/92-10/92 and at hosp B from 5/93-9/93. Patients with neoplasms were excluded |
| Upper GI Tract endoscopy 3 | 17% overall; varied from 15% to 19% among sites | 11% overall; varied from 8% to 14% among sites | 5 sites of varying utilization for the 3 procedures selected from Medicare claims submitted by physicians in Arkansas, Colorado, Iowa, Mass., Montana, Penn., S. Carolina, and N. Calif. | Random sample of Medicare beneficiaries for each procedure (claims submitted in 1981) at each site (high, average, and low use geographic areas) |
| Upper GI Tract endoscopy 4 | Varied by county from 0%-25% | Not evaluated | 23 adjacent rural and urban, large and small, counties in one large, populous state | Sampled procedures by Medicare billing codes performed on 614 UGI patients in 1981, aged 65 years and older |
From: APPENDIX 8, Literature Tables for Utilization and ACSC Indicators
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.