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Mark R. Chassin, MD, MPP, MPH; R. E. Park, PhD
The RAND Corporation Santa Monica, Calif

Robert H. Brook, MD, ScD; David H. Solomon, MD, MACP
University of California at Los Angeles School of Medicine

Jacqueline Kosecoff, PhD; Arlene Fink, PhD
Fink and Kosecoff Santa Monica, Calif

JAMA. 1988;259(13):1948.

	Since this article does not have an abstract, we have provided the first 150 words of the full text PDF and any section headings.

In Reply.

—We agree with Dr Caper that large geographic areas are different from small ones. Variations among large areas may be less extreme and their causes may be different than those in small areas. However, the large areas we studied exhibited variations of great magnitude, for example, the 3.8-fold difference between our highest- and lowest-use sites for carotid endarterectomy. If the site with the highest use rate had actually experienced the rate of the site with the lowest rate, more than 1000 fewer carotid endarterectomies would have been performed at that site in 1981.

We have described, analyzed, and reported in detail our method of rating appropriateness.^1-4 The ratings that result from this process are reproducible, consistent with clinical research, and in accord with clinical theory. We are unaware of any similar body of data supporting the reliability and validity of other methods of developing appropriateness standards to . . . [Full Text PDF of this Article]

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