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A Study of Three Procedures

Mark R. Chassin, MD, MPP, MPH; Jacqueline Kosecoff, PhD; R.E. Park, PhD; Constance M. Winslow, MD; Katherine L. Kahn, MD; Nancy J. Merrick, MD, MSPH; Joan Keesey; Arlene Fink, PhD; David H. Solomon, MD; Robert H. Brook, MD, ScD

JAMA. 1987;258(18):2533-2537.

Abstract
We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significant levels of inappropriate use:17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

(JAMA 1987;258:2533-2537)

Author Affiliations
From the Health Program of The Rand Corp (Drs Chassin, Park, Kahn, and Brook, and Ms Keesey) and Fink and Kosecoff Inc (Drs Kosecoff and Fink), Santa Monica, Calif; and the Departments of Medicine (Drs Kosecoff, Winslow, Kahn, Merrick, Fink, Solomon, and Brook) and Public Health (Drs Kosecoff, Fink, and Brook), University of California at Los Angeles.

Footnotes
The opinions, conclusions, and proposals in the text are those of the authors alone and do not necessarily represent the views of any of these organizations, The Rand Corp, or the University of California.

Reprint requests to The Rand Corp, 1700 Main St, PO Box 2138, Santa Monica, CA 90406-2138 (Dr Chassin).

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