Appropriateness of upper gastrointestinal endoscopy: comparison of American and Swiss criteria.

OBJECTIVE: Examine the reproducibility of the RAND method for developing criteria for the appropriateness of medical procedures. DESIGN: Comparison of two sets of explicit criteria for appropriateness of upper gastrointestinal (UGI) endoscopy, developed by separate expert panels from two countries. SETTING: United States, Switzerland. STUDY PARTICIPANTS: National experts from different medical specialties involved in the referral or application of UGI endoscopy. INTERVENTIONS: Each panel was presented with about 500 clinical scenarios (indications) that were rated on a nine-point scale as to the appropriateness of performing UGI endoscopy for a patient with that clinical presentation. MAIN OUTCOME MEASURES: (1) distribution of appropriateness ratings and intrapanel agreement categories between the two panels, (2) between-panel agreement of assigning appropriateness for comparable indications and, (3) percentage of indications with major between-panel differences. RESULTS: Ratings for 2/3 of indications could be compared. The Swiss panel showed higher intrapanel agreement (54.6% versus 46.2%, P = 0.002). Seventy-eight per cent of comparable indications were assigned to identical categories of appropriateness by both panels (kappa = 0.76, P < 0.001). For 93% of the 376 comparable indications, there were no major interpanel differences. CONCLUSION: Separate expert panels in different countries, using a standardized methodology, produce criteria for appropriateness of medical procedures that are similar. Given the resources being invested throughout the world in developing criteria and guidelines, international collaboration in seeking optimal use of limited health care resources should be intensified.

[Use of the International Classification of Diseases for disability insurance in Switzerland: study of reproducibility]. / Utilisation de la classification internationale des maladies dans l'asurance-invalidité en Suisse: étude de reproductibilité.

The International Classification of Diseases (ICD-10) was introduced in a pilot phase for coding of diagnoses in a sample of cases encountered in the Swiss Disability Insurance (SDI), as a substitute for the SDI codes, judged unsuitable for the description of disability. The goal of this study is to evaluate the reliability of use of these codes, by studying the coding reproductibility between the Medical Observation Centers (MOC) and the Evaluation and Coordination Center. A second goal was to evaluate the feasibility of coding by non-physicians. Reliability of diagnoses was examined by level of precision: chapters, groups, categories and subcategories. The agreement between the two coding Centers varies from 78%, at the chapter level, to 29% at the most detailed level. This agreement is improved if taking into account the three main diagnoses for the comparison, reaching 91%. The results of the physician coder, concerning the precision and reliability of coding, are significantly superior to those of an economist coder and a medical secretary coder. To improve coding agreement, it is proposed to train coding professionals, provide coding tools, clarify which diagnosis is the main one, and seek a consensus for cases of systematic disagreement. The ideal level of precision should not be so high as to produce diagnostic codes with low reliability. It should, however, be precise enough to give a satisfactory description of the problems encountered.

Quality of work incapacity assessment in the Swiss disability insurance system.

Quality of medical assessment of work incapacity has been poorly investigated, despite the enormous costs engendered by transient incapacity of work and permanent disability. This study examined some indices of quality from a stratified, random sample (n = 120) of assessments performed by expert assessors of the Swiss disability insurance. The distribution of work incapacity (WI) percentages over a 100% scale showed a clustering around key values significantly associated with financial disability benefits. The precision of WI, expressed as the level of quantitative exactness, was found to be high in 74% (95% CI: 66-82%) of current WI assessments, and in 62% (95% CI: 53-71%) of maximal WI assessments. Disagreement was observed in 17% of cases when comparing two ways of expressing WI by the same physician (95% CI: 10-23%). This exploratory study is limited by the general lack of objective criteria and standards. Further theoretical and empirical developments are needed to determine standardized criteria and clear guidelines for medical assessments of WI, as well as for evaluating their quality.

[Variations in referral to specialized medical centers of the Swiss disability insurance: role of the referring party]. / Variations dans le recours aux centres d'expertises de l'assurance-invalidité en Suisse: le rôle des mandants.

The Commissions of the Swiss Disability Insurance (CDI), in order to evaluate the degree of disability which determines the right to benefits, can call upon Medical Observation Centers (MOCD) for a pluridisciplinary examination. The utilization rate of the MOCD, by the 28 CDI, varies by a factor of 1 to 50. The goal of this study is to identify the causes of this variation related to the differences in CDI practice. The CDI answered a mail survey. For analysis, they are allocated into 3 groups of equal size: Low, medium and high users of MOCD. There is no association between the use of the official and non-official criteria for referral to MOCD and utilization rate of the MOCD. The CDI have a false perception of their MOCD use; 40% of them underestimate it. Considering together the utilization rate of the substitutes and of the MOCD, variation still persists from 1 to 9 among the CDI. There is no difference in the reasons for non-referral to the MOCD according to the level of utilization. This study failed to identify the causes of the utilization differences of the MOCD by the CDI. Other factors should be examined.

[Variations by canton in the use of medical observation centers of the disability-insurance in Switzerland]. / Variations cantonales dans l'utilisation des Centres d'observation médicale de l'assurance-invalidité en Suisse.

The Medical Observation Centres of the state Disability Insurance (COMAI) are specialized agencies serving the cantonal commissions of the Disability Insurance in Switzerland. Using data collected for each case examined by the COMAI, utilisation rates and rankings were established for each canton. Utilisation rates varied by a factor of 40 from one canton to the next. This observed variation is independent of the number of new cases presenting to the Disability Insurance and of the number of disability pensions granted. Rankings were also independent of denominators used to define utilisation rates. These results suggest possible non-uniform application of state directives concerning the use of the COMAI, and unequal access to these specialized agencies. The reasons for these variations are the object of a study now underway.