The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis.

Essentials How best to quantify thrombosis risk with peripherally inserted central catheters (PICC) is unknown. Data from a registry were used to develop the Michigan Risk Score (MRS) for PICC thrombosis. Five risk factors were associated with PICC thrombosis and used to develop a risk score. MRS was predictive of the risk of PICC thrombosis and can be useful in clinical practice. SUMMARY: Background Peripherally inserted central catheters (PICCs) are associated with upper extremity deep vein thrombosis (DVT). We developed a score to predict risk of PICC-related thrombosis. Methods Using data from the Michigan Hospital Medicine Safety Consortium, image-confirmed upper-extremity DVT cases were identified. A logistic, mixed-effects model with hospital-specific random intercepts was used to identify factors associated with PICC-DVT. Points were assigned to each predictor, stratifying patients into four classes of risk. Internal validation was performed by bootstrapping with assessment of calibration and discrimination of the model. Results Of 23 010 patients who received PICCs, 475 (2.1%) developed symptomatic PICC-DVT. Risk factors associated with PICC-DVT included: history of DVT; multi-lumen PICC; active cancer; presence of another CVC when the PICC was placed; and white blood cell count greater than 12 000. Four risk classes were created based on thrombosis risk. Thrombosis rates were 0.9% for class I, 1.6% for class II, 2.7% for class III and 4.7% for class IV, with marginal predicted probabilities of 0.9% (0.7, 1.2), 1.5% (1.2, 1.9), 2.6% (2.2, 3.0) and 4.5% (3.7, 5.4) for classes I, II, III, and IV, respectively. The risk classification rule was strongly associated with PICC-DVT, with odds ratios of 1.68 (95% CI, 1.19, 2.37), 2.90 (95% CI, 2.09, 4.01) and 5.20 (95% CI, 3.65, 7.42) for risk classes II, III and IV vs. risk class I, respectively. Conclusion The Michigan PICC-DVT Risk Score offers a novel way to estimate risk of DVT associated with PICCs and can help inform appropriateness of PICC insertion.

Quality of life of patients with chronic stable angina before and four years after coronary revascularisation compared with a normal population.

OBJECTIVE: To assess the impact of coronary revascularisation on the health related quality of life (HRQOL) of patients with chronic stable angina compared with data from "community" norms four years following revascularisation. DESIGN: Prospective survey and review of medical records. SETTING: Seven of the eight public Swedish heart centres that performed coronary artery interventions. SUBJECTS: 827 patients aged 55-79 years with chronic stable angina who underwent coronary artery revascularisation in 1994 or 1995 and completed the four year HRQOL survey. MAIN OUTCOME MEASURES: Five components of the Swedish quality of life survey. RESULTS: Compared with age and sex adjusted population norms, patients at baseline had significantly lower mean scores on all five functioning and wellbeing scales (p < 0.001). Four years after revascularisation, the mean levels of functioning and wellbeing were similar to those in the normative population (p > 0.05) except for quality of sleep (p < 0.001). The improvements were the same across age groups and for men and women. However, 36% of men and 55% of women were not completely free from angina by four years (p < 0.001). Men without angina after four years had better HRQOL than their community norms (p < 0.001) on all dimensions except quality of sleep (p > 0.05). Women without angina had less pain (p < 0.01) and better general health perception (p < 0.05) but similar physical functioning, quality of sleep, and emotional wellbeing compared with their community counterparts. Both men and women who had suffered at least one anginal attack during the preceding four weeks had significantly worse HRQOL by four years than their community norms (p < 0.01). CONCLUSIONS: By four years following revascularisation, three fifths of patients with chronic stable angina were free of angina and their HRQOL was the same as or better than that of the general Swedish population. However, fewer than half of all women and two thirds of men who underwent revascularisation were angina-free after four years. Among patients with new or persistent angina, the HRQOL was worse than that in community norms.

Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy.

There is no empirical evidence on the sensitivity and specificity of methods to identify the possible overuse and underuse of medical procedures. To estimate the sensitivity and specificity of the RAND/UCLA Appropriateness Method. Parallel three-way replication of the RAND/UCLA Appropriateness Method for each of two procedures, coronary revascularization and hysterectomy. Maximum likelihood estimates of the sensitivity and specificity of the method for each procedure. These values were then used to re-calculate past estimates of overuse and underuse, correcting for the error rate in the appropriateness method. The sensitivity of detecting overuse of coronary revascularization was 68% (95% confidence interval 60-76%) and the specificity was 99% (98-100%). The corresponding values for hysterectomy were 89% (85-94%) and 86% (83-89%). The sensitivity and specificity of detecting the underuse of coronary revascularization were 94% (92-95%) and 97% (96-98%), respectively. Past applications of the appropriateness method have overestimated the prevalence of the overuse of hysterectomy, underestimated the prevalence of the overuse of the coronary revascularization, and provided true estimates of the underuse of revascularization. The sensitivity and specificity of the RAND/UCLA Appropriateness Method vary according to the procedure assessed and appear to estimate the underuse of procedures more accurately than their overuse.

Liquid-based cervical cytologic smear study and conventional Papanicolaou smears: a metaanalysis of prospective studies comparing cytologic diagnosis and sample adequacy.

OBJECTIVE: We sought to evaluate the cytologic diagnosis and sample adequacy of the liquid-based cervical cytologic smear (ThinPrep) compared with that of the conventional Papanicolaou smear. STUDY DESIGN: Prospective studies of ThinPrep and conventional Papanicolaou smears were analyzed for cytologic diagnosis and sample adequacy. Computerized databases, references in published studies, and index reviews published in English were used to identify direct-to-vial and split-sample clinical trials of cervical smears performed by conventional and liquid-based techniques. Only published studies that used the Bethesda system nomenclature with clearly documented outcome data were included. Each trial was assessed for the quality of its method, inclusion and exclusion criteria, adequacy of randomization, sampling protocols, definition of outcome, and statistical analyses. RESULTS: Twenty-five studies met inclusion criteria for this review. Odds ratios with 95% confidence intervals were calculated for each outcome. Estimates of odds ratios and risk differences for dichotomous outcomes were calculated by use of random and fixed-effects models. Homogeneity was tested across the studies. Results indicate that the ThinPrep test is as good as or superior to the conventional Papanicolaou smear in diagnosing uterine cervical premalignant abnormalities. Also the ThinPrep test provides improved sample adequacy when compared with the conventional Papanicolaou test. CONCLUSION: The ThinPrep test improved sample adequacy and led to improved diagnosis of low-grade and high-grade squamous intraepithelial lesions. However, there is no difference in the rate of atypical cells of undetermined significance diagnosis between ThinPrep and conventional smear groups. The added cost of ThinPrep cytologic screening and, hence, its cost-effectiveness are not evaluated in this study.

Assessing symptoms before hysterectomy: is the medical record accurate?

OBJECTIVE: Our purpose was to evaluate the agreement between the documentation of symptoms leading to hysterectomy and the assessment of those symptoms by the patient. STUDY DESIGN: A retrospective study was performed of 497 women in southern California who had hysterectomies. Sensitivity, specificity, and kappa statistics were calculated for the medical records and were compared with patient interviews for the presence and severity of symptoms. RESULTS: The medical record was 93% sensitive and 61% specific for identifying bleeding and 79% sensitive and 55% specific for identifying pain. Overall agreement between physician records and patient interviews was moderate for bleeding (kappa, 0.55-0.58), fair for pain (kappa, 0.29-0.34), and poor for impairment as a result of bleeding or pain (kappa, 0.0-0.14). CONCLUSIONS: Physician overestimation of symptoms could lead to overuse of hysterectomy, whereas underestimation could result in underuse. Our results suggest that both underestimation and overestimation occur for patients with abnormal bleeding, pain, or both. If physicians accurately assess symptoms but fail to document them, examinations of appropriateness will be faulty unless patients are interviewed.

The appropriateness of use of percutaneous transluminal coronary angioplasty in Spain.

BACKGROUND: The rapid increase in the number of percutaneous transluminal coronary angioplasty (PTCA) procedures performed in Spain in recent years raises questions about how appropriately this procedure is being used. To examine this issue, we studied the appropriateness of use of PTCA in Spanish patients and factors associated with inappropriate use. METHODS: We applied criteria for the appropriate use of PTCA developed by an expert panel of Spanish cardiologists and cardiovascular surgeons to a random sample of 1913 patients undergoing PTCA in Spain in 1997. The patients were selected through a two-step sampling process, stratifying by hospital type (public/private) and volume of procedures (low/medium/high). We examined the association between inappropriate use of PTCA and different clinical and sociodemographic factors. RESULTS: Overall, 46% of the PTCA procedures were appropriate, 31% were uncertain and 22% were inappropriate. Two factors contributing to inappropriate use were patients' receipt of less than optimal medical therapy and their failure to undergo stress testing. Institutional type and volume of procedures were not significantly related with inappropriate use. CONCLUSIONS: One of every five PTCA procedures in Spain is done for inappropriate reasons. Assuring that patients receive optimal medical therapy and undergo stress testing when indicated could contribute to more appropriate use of PTCA.

Effect of specialty and nationality on panel judgments of the appropriateness of coronary revascularization: a pilot study.

BACKGROUND: Appropriateness criteria are frequently used to assess quality of care. However, assessing care in one country with criteria developed in another may be misleading. One approach to measuring care across countries would be to develop common standards using physicians from different countries and specialties. OBJECTIVE: To identify the degree to which appropriateness ratings for coronary revascularization developed by a multinational panel differ by panelist specialty and nationality. METHODS: A 13-member panel of cardiothoracic surgeons and cardiologists from the Netherlands, Spain, Sweden, Switzerland, and the United Kingdom was convened to rate the appropriateness of 842 indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG) on a 1 (extremely inappropriate) to 9 (extremely appropriate) scale. MEASURES: Mean appropriateness ratings by panelist specialty and nationality. RESULTS: Surgeons' mean ratings for PTCA indications ranged from 0.64 points lower than the corresponding ratings of the cardiologists for acute myocardial infarction indications to 1.22 points lower for chronic stable angina indications. Conversely, their ratings for bypass surgery indications ranged from 0.59 points higher for chronic stable angina indications to 0.69 points higher for unstable angina indications. Although Spanish panelists' ratings were significantly higher than the mean for 3 of the 4 clinical conditions treated by PTCA, their ratings were similar for bypass surgery indications. No specific patterns were observed in the ratings of the panelists from the other countries. CONCLUSIONS: These findings support the use of physicians from multiple specialties on appropriateness panels because they represent more divergent views than physicians from a single specialty. Finding no systematic difference in beliefs regarding the appropriateness of PTCA and CABG among physicians from different countries will require confirmation before multinational panels supplant single country panels in future studies.

Quality of life of chronic stable angina patients 4 years after coronary angioplasty or coronary artery bypass surgery.

OBJECTIVE: To evaluate the quality of life experienced by chronic stable angina patients with one- or two-vessel coronary artery disease treated with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 601 Swedish chronic stable angina patients with one- or two-vessel disease who underwent CABG (n = 252) or PTCA (n = 349) between May 1994 and January 1995. MAIN OUTCOME MEASURES: We assessed five components of the Swedish Quality of Life Survey, anginal frequency, sublingual nitroglycerin use, and survival at 6, 21 and 48 months following coronary revascularization. RESULTS: Anginal frequency and sublingual nitroglycerin use decreased for all patients by 6 months, but more amongst surgery patients than amongst angioplasty patients (P < 0.05). At 48 months, more bypass patients reported that they had not used sublingual nitroglycerin during the preceding 4 weeks (73.1 vs. 63.4%, P < 0.05). At 6 months, bypass patients had greater levels of improvement in physical functioning (15.3 vs. 10.5, P < 0.05) and general health perception (16.5 vs. 10.2, P < 0.05) than angioplasty patients. Bypass patients also had better relief from pain (19.4 vs. 14.6, P < 0.05), quality of sleep (17.6 vs. 4.6, P < 0.05) and general health perception (17.3 vs. 12.1, P < 0.05) at 21 months. By 48 months follow-up, there was no longer any difference in these measures between groups. CONCLUSIONS: Both bypass surgery and angioplasty lead to improved quality of life for patients with chronic stable angina and one- or two-vessel coronary artery disease. Bypass surgery is associated with better quality of life at 6 months, but by 48 months quality of life is similar for patients initially treated by either procedure.

European criteria for the appropriateness and necessity of coronary revascularization procedures.

OBJECTIVES: Large variations in the use of coronary revascularization procedures have led many countries to apply the RAND appropriateness method to develop specific criteria describing patients who should be offered these procedures. The method is based on the work of a multidisciplinary expert panel that reviews a synthesis of the scientific evidence and rates the appropriateness of a comprehensive list of indications for the procedure being studied. Previous studies, however, have all involved single-country panels. We tested the feasibility of carrying out a multinational panel to rate the appropriateness and necessity of coronary revascularization, thereby producing recommendations for common European criteria. METHODS: Using the RAND methodology, a multispecialty (interventional cardiologists, non-interventional cardiologists and cardiovascular surgeons), multinational (The Netherlands, Spain, Sweden, Switzerland and the United Kingdom) panel rated the appropriateness and necessity of indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). A synthesis of the evidence and list of indications for PTCA and CABG were sent to 15 panelists, three from each country, who performed their ratings in three rounds. RESULTS: For PTCA, 24% of the indications were appropriate and necessary, 16% were appropriate, 43% were uncertain and 17% were inappropriate. The corresponding values for CABG were 33% appropriate and necessary, 7% appropriate, 40% uncertain and 20% inappropriate. The proportion of indications rated with disagreement was 4% for PTCA and 7% for CABG. CONCLUSION: Multinational panels appear to be a feasible method of addressing issues concerning the appropriateness and necessity of medical procedures in western European countries. The criteria produced provide a common tool that can be used to measure the overuse and underuse of medical procedures and to guide decision-making.

Are physicians aware of which of their patients have indwelling urinary catheters?

PURPOSE: Although infections associated with indwelling urinary catheters are common, costly, and morbid, the use of these catheters is unnecessary in more than one-third of patients. We sought to assess whether attending physicians, medical residents, and medical students are aware if their hospitalized patients have an indwelling urinary catheter, and whether physician awareness is associated with appropriate use of these catheters. METHODS: The physicians and medical students responsible for patients admitted to the medical services at four university-affiliated hospitals were given a list of the patients on their service. For each patient, the provider was asked: "As of yesterday afternoon, did this patient have an indwelling urethral catheter?" Respondents' answers were compared with the results of examining the patient. RESULTS: Among 288 physicians and students on 56 medical teams, 256 (89%) completed the survey. Of 469 patients, 117 (25%) had an indwelling catheter. There were a total of 319 provider-patient observations among these 117 patients. Overall, providers were unaware of catheterization for 88 (28%) of the 319 provider-patient observations. Unawareness rates by level of training were 21% for students, 22% for interns, 27% for residents, and 38% for attending physicians (P = 0.06). Catheter use was inappropriate in 36 (31%) of the 117 patients with a catheter. Providers were unaware of catheter use for 44 (41%) of the 108 provider-patient observations of patients who were inappropriately catheterized. Catheterization was more likely to be appropriate if respondents were aware of the catheter (odds ratio = 3.7; 95% confidence interval, 2.1 to 6.7, P <0.001). CONCLUSION: Physicians are commonly unaware that their patients have an indwelling urinary catheter. Inappropriate catheters are more often "forgotten" than appropriate ones. System-wide interventions aimed at discontinuing unnecessary catheterization seem warranted.

Comparing physician and administrator responses to cesarean section guidelines and actual practice.

BACKGROUND: A cross-sectional study was conducted in 1996 to determine to what extent hospitals have adopted guidelines to improve the appropriate use of cesarean section (C-section); discover attitudes of obstetricians toward C-section guidelines; and explore how physician attitudes toward guidelines interact with organizational features. METHODS: The study consisted of two components: (1) Telephone interviews with hospital administrators from Michigan hospitals providing obstetric care (response rate: 100%); these interviews were intended to determine whether guidelines were in use and the processes for their development and implementation. (2) A self-administered mail survey assessing the attitudes of 266 Michigan obstetricians (response rate: 57%), intended to assess their attitudes toward the content and effects of C-section guidelines. RESULTS: Twenty-nine percent of hospitals were using C-section guidelines, according to reports from hospital administrators. Mean C-section rates were not significantly different between hospitals using guidelines and those not using guidelines (23.2% and 22.4%, p = 0.49). More than 80% of physicians felt that the guidelines were supported by the literature and were applicable in daily practice, and agreed with their ideas about C-section performance, and 67% reported that guidelines would have no or minimal effect on their practice. However, only 55% of physicians and administrators agreed on the presence or absence of guidelines at their hospital (kappa = 0.09). DISCUSSION: Physicians appear to agree with guidelines and believe they are already following them, despite high C-section rates. Physicians' attitudes toward guidelines are not necessarily a reflection of actual practice. If C-section guidelines are to decrease excessive C-section rates, stronger, more integrated implementation strategies are needed.

Improving HEDIS measurement: linking managed care organization and health system ambulatory care data.

This article describes one health system's efforts to improve HEDIS measurement by integrating claims information from its managed care organization with data from its medical center's automated billing, scheduling, and clinical information systems. The authors discuss problems encountered while establishing an integrated measurement process and offer suggestions for others considering such an approach.

Effect of physician specialty on treatment recommendation to patients with coronary artery disease.

OBJECTIVE: To assess the influence of physician specialty and the way in which patient data are presented in the treatment recommended for patients with coronary artery disease. METHODS: In a prospective study, 3,628 patients with significant coronary artery disease who had been referred to 1 of 10 heart centers in the Netherlands as possible candidates for either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) were recruited. Within each center, the recommended treatment is determined by a team consisting of cardiologists only, cardiovascular surgeons only, or cardiologists and cardiovascular surgeons (i.e., composite teams). The main outcome measures are the proportions of patients for whom PTCA, CABG, or noninvasive (medical) therapy was recommended. RESULTS: Composite teams made 71% of recommendations, surgeon-only teams, 12%, and cardiologist-only teams, 17%. Cardiologist-only teams primarily recommended patients to PTCA, surgeon-only teams to CABG, while combined teams made more evenly distributed recommendations (p < .001). Although the patients discussed by the three types of teams were clinically different, the recommendation patterns remained significant after adjusting for these differences (p < .001). For patients with recent myocardial infarction, direct presentation of the case to the team by the referring cardiologist reduced the likelihood that CABG would be recommended. CONCLUSIONS: The treatment recommended to patients with coronary artery disease is affected by the composition of the team providing the recommendation. These findings have important implications for clinical decision making for patients with cardiovascular disease.

The appropriateness of recommendations for hysterectomy.

OBJECTIVE: To evaluate the appropriateness of recommendations for hysterectomies done for nonemergency and non-oncologic indications. METHODS: We assessed the appropriateness of recommendations for hysterectomy for 497 women who had the operation between August 1993 and July 1995 in one of nine capitated medical groups in Southern California. Appropriateness was assessed using two sets of criteria, the first developed by a multispecialty expert physician panel using the RAND/University of California-Los Angeles appropriateness method, and the second consisting of the ACOG criteria sets for hysterectomies. The main outcome measure was the appropriateness of recommendation for hysterectomy, based on expert panel ratings and ACOG criteria sets. RESULTS: The most common indications for hysterectomy were leiomyomata (60% of hysterectomies), pelvic relaxation (11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level of care recommended by the expert panel and were judged to be recommended inappropriately. ACOG criteria sets were applicable to 71 women, and 54 (76%) did not meet ACOG criteria for hysterectomy. The most common reasons recommendations for hysterectomies considered inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy. CONCLUSION: Hysterectomy is often recommended for indications judged inappropriate. Patients and physicians should work together to ensure that proper diagnostic evaluation has been done and appropriate treatments considered before hysterectomy is recommended.

Discussion between reviewers does not improve reliability of peer review of hospital quality.

OBJECTIVES: Peer review is used to make final judgments about quality of care in many quality assurance activities. To overcome the low reliability of peer review, discussion between several reviewers is often recommended to point out overlooked information or allow for reconsideration of opinions and thus improve reliability. The authors assessed the impact of discussion between 2 reviewers on the reliability of peer review. METHODS: A group of 13 board-certified physicians completed a total of 741 structured implicit record reviews of 95 records for patients who experienced severe adverse events related to laboratory abnormalities while in the hospital (hypokalemia, hyperkalemia, renal failure, hyponatremia, and digoxin toxicity). They independently assessed the degree to which each adverse event was caused by medical care and the quality of the care leading up to the adverse event. Working in pairs, they then discussed differences of opinion, clarified factual discrepancies, and rerated the record. The authors compared the reliability of each measure before and after discussion, and between and within pairs of reviewers, using the intraclass correlation coefficient for continuous ratings and the kappa statistic for a dichotomized rating. RESULTS: The assessment of whether the laboratory abnormality was iatrogenic had a reliability of 0.46 before discussion and 0.71 after discussion between paired reviewers, indicating considerably improved agreement between the members of a pair. However, across reviewer pairs, the reviewer reliability was 0.36 before discussion and 0.40 after discussion. Similarly, for the rating of overall quality of care, reliability of physician review went from 0.35 before discussion to 0.58 after discussion as assessed by pair. However, across pairs the reliability increased only from 0.14 to 0.17. Even for prediscussion ratings, reliability was substantially higher between 2 members of a pair than across pairs, suggesting that reviewers who work in pairs learn to be more consistent with each other even before discussion, but this consistency also did not improve overall reliability across pairs. CONCLUSIONS: When 2 physicians discuss a record that they are reviewing, it substantially improves the agreement between those 2 physicians. However, this improvement is illusory, as discussion does not improve the overall reliability as assessed by examining the reliability between physicians who were part of different discussions. This finding may also have implications with regard to how disagreements are resolved on consensus panels, guideline committees, and reviews of literature quality for meta-analyses.

Issues in the development, dissemination, and effect of an evidence-based guideline for managing sore throat in adults.

BACKGROUND: In October 1995 the University of Michigan Healthcare System initiated a program to develop and implement guidelines for primary care in an effort to improve the quality and cost-effectiveness of care for common conditions associated with wide variations in clinical practice. One of these conditions was Group A beta-hemolytic streptococcus (GABHS), present in 5% to 20% of adults complaining of sore throat. METHODS: A draft guideline was developed on the basis of a theoretical model of sore throat management, local data, and research evidence. The guideline was revised to reflect physicians' beliefs and practices regarding sore throat management. Guideline recommendations depended only on the number of clinical signs experienced by the patient and included testing only if it was likely to provide additional information about the probability of GABHS. Data on pre- and postdissemination data on patients presenting with sore throat were collected. RESULTS: When physicians believed testing or antibiotics were unnecessary, only 7% of patients demanded screening and only 6% of patients wanted antibiotics. Physician beliefs about a patient's need for testing agreed with guideline recommendations in 63% of patients both before and after guideline dissemination. DISCUSSION: Disseminating locally modified, evidence-based guidelines may not be sufficient to produce practice changes. If the guideline had been followed, the amount of testing would have been reduced by 17% and the appropriateness of testing improved for 32% of sore throat patients. The results indicate the need for implementation efforts that go beyond presenting evidence, even when that evidence is from both the literature and the local practice setting.

Quality of life among women undergoing hysterectomies.

OBJECTIVE: To measure the association between gynecologic conditions and quality of life in women before hysterectomy. METHODS: We retrospectively identified 482 women who had hysterectomies for nononcologic and nonemergency indications in one of nine capitated medical groups in Southern California between 1993 and 1995. Their symptoms and quality of life before hysterectomy were assessed by medical record review and telephone interview. Women were placed into four symptom-based groups (pain, bleeding, pelvic discomfort, and asymptomatic groups) and compared across six quality-of-life scales. RESULTS: Women with primary pain conditions reported the highest average role impairment compared with women with primary bleeding, pelvic discomfort, or asymptomatic conditions (8.6 days/month versus 5.0, 2.5, and 1.9 days/month, respectively; P < .05). On the five 0 to 100-point quality-of-life scales, women with primary pain conditions, compared with women with bleeding, pelvic discomfort, or asymptomatic conditions, had the highest mean levels of sexual impairment (71.5 versus 54.1, 29.6, and 17.9, respectively; P < .05) and mood impairment (55.2 versus 45.2, 34.6, and 38.1, respectively; P < .05), the poorest perception of general health (74.4 versus 60.7, 44.1, and 49.4, respectively; P < .05), and the greatest increase in severity of symptoms before hysterectomy (77.2 versus 68.7, 61.5, and 57.1, respectively; P < .05). CONCLUSION: Women's primary symptoms before hysterectomy are associated differentially with varying levels of impairment. Standardized measurement of quality of life among women with gynecologic complaints that lead to hysterectomy might help in the development of treatment guidelines and in the assessment of appropriateness and outcomes of care for those women.

Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group.

OBJECTIVE: To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES: Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS: Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS: Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.