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.

Underutilization of upper gastrointestinal endoscopy.

BACKGROUND & AIMS: Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy. METHODS: Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic. RESULTS: During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients. CONCLUSIONS: This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.

[Screening for colorectal tumors using fecal occult blood studies]. / Dépistage des tumeurs colorectales par la recherche de sang occulte dans les selles.

Guaiac tests such as Hemoccult are widely used but are affected by several factors. Occult blood testing does uncover subclinical colorectal cancer often at early stage, but a favorable effect on survival remains to be proven. The sensitivity for the detection of malignancies is from moderate to good, but it is poor for benign polyps. Predictive value of a positive test for cancer ist about 8-12%. Thus, most of the individuals with a positive test would not need colonic investigations. Recommendations relating to the testing for of occult blood could change rapidly with the new immunologic techniques or with new data on mortality coming from controlled clinical trial now being conducted.