Ayanian J Z, Landrum M B, Normand S L, Guadagnoli E, McNeil B J
Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
N Engl J Med. 1998 Jun 25;338(26):1896-904. doi: 10.1056/NEJM199806253382608.
Evaluations of the appropriateness of medical care are important to monitor the quality of care and to contain costs and enhance safety by reducing inappropriate care. Experts' views are usually incorporated into evaluations of appropriateness. However, practicing physicians may not concur with these views, and physicians' clinical backgrounds may influence their beliefs.
We asked 1058 internists, family practitioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas to rate the appropriateness of coronary angiography after acute myocardial infarction for 20 common indications. Nine clinical experts also rated these indications using an established consensus method.
For 17 of the 20 indications, median ratings of surveyed physicians and the expert panel agreed within 1 unit on a 9-unit scale. Patients' older age had a negative effect on ratings by the expert panel but not on ratings by surveyed physicians. In multivariable analyses of surveyed physicians, cardiologists rated angiography as significantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who performed invasive procedures gave higher appropriateness ratings for angiography than did cardiologists who did not perform such procedures and primary care physicians. For uncomplicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than other physicians.
Surveyed physicians agreed with clinical experts about the appropriateness of coronary angiography after myocardial infarction for most indications, indicating that well-designed expert panels can closely reflect the views of practicing physicians. Variations in beliefs among practicing physicians suggest that evaluations of medical practice should incorporate the views of a range of relevant types of physicians.
评估医疗护理的适宜性对于监测护理质量、控制成本以及通过减少不适当护理来提高安全性至关重要。专家的观点通常会纳入适宜性评估中。然而，执业医师可能不同意这些观点，并且医师的临床背景可能会影响他们的信念。
我们邀请了加利福尼亚州、佛罗里达州、纽约州、宾夕法尼亚州和得克萨斯州的1058名内科医生、家庭医生和心脏病专家，对急性心肌梗死后冠状动脉造影针对20种常见适应症的适宜性进行评分。九名临床专家也使用既定的共识方法对这些适应症进行了评分。
在20种适应症中的17种，被调查医师和专家小组的中位数评分在9分制的1分范围内一致。患者年龄较大对专家小组的评分有负面影响，但对被调查医师的评分没有影响。在对被调查医师的多变量分析中，对于复杂适应症，心脏病专家对血管造影的适宜性评分显著高于初级保健医生；对于非复杂适应症，进行侵入性操作的心脏病专家对血管造影的适宜性评分高于未进行此类操作的心脏病专家和初级保健医生。对于非复杂适应症，提供冠状动脉成形术和搭桥手术的医院的医师对血管造影的适宜性评分高于其他医院的医师。来自纽约的医师以及受健康维护组织雇佣的医师对血管造影的适宜性评分低于其他医师。
对于大多数适应症，被调查医师与临床专家在心肌梗死后冠状动脉造影的适宜性方面意见一致，这表明精心设计的专家小组能够密切反映执业医师的观点。执业医师信念的差异表明，医疗实践评估应纳入一系列相关类型医师的观点。
