Appropriateness of referrals for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a developing community: A comparison between 2005 and 2009 versions of ACCF/ASNC appropriateness criteria

Appropriateness of referrals for myocardial perfusion imaging (MPI) in developing countries has not been extensively studied. Our study was conducted to describe the ordering practices of physicians and appropriateness of MPI referrals in Iran. We prospectively applied 2005 and 2009 versions of the Appropriateness Use Criteria published by the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) to 291 consecutive patients (age 55.3 ± 10.3 years) who underwent SPECT-MPI. For this purpose, we convened a panel, consisting of two academic cardiologists, one academic clinician in internal medicine, and one academic clinician in nuclear medicine. The panelists were invited for a face-to-face meeting to judge appropriateness of SPECT-MPI and independently assign a specific indication (scenario), whenever possible, for each case in accordance with ACCF/ASNC appropriateness scenarios. Based on the 2005 ACCF/ASNC criteria, SPECT-MPI studies were judged appropriate for 211 (72.5%), uncertain for 36 (12.4%), inappropriate for 32 (11.0%), and unclassifiable for 12 (4.1%) referrals. The same figures based on the 2009 version were 219 (75.3%), 15 (5.2%), 49 (16.8%), and 8 (2.7%) patients, respectively. Overall agreement between the 2005 and 2009 versions was good (κ 0.63). Lack of chest pain and age below 60 years were significant indicators increasing the likelihood of inappropriate referrals by 2.9-3.4 fold. Absence of diabetes mellitus and hypertension, a normal lipid profile, lack of a past history of myocardial infarction or cardiovascular interventions (CABGs or PCI), as well as lack of application and exercise ECG stress test as the gate keeper (keeping abnormal ETT or inability of the patient to perform exercise as the appropriate indication for SPECT-MPI referral) were significant indicators, decreasing the odds of appropriate referrals. Generally a higher percentage of referrals with inappropriate indications had normal MPI. Our study provides an evidence for the fact that SPECT-MPI ordering practices in our developing community largely parallel the ACCF/ASNC recommendations. The implementation of appropriateness criteria is feasible in clinical settings and might provide an alternative to utilization management. © 2011 American Society of Nuclear Cardiology

Rhetoric appropriateness in view of contemporary media communication and journalism

In the article, I present deliberations on the theme of the rhetorical category of appropriateness in the context of its original sources and contemporary media practice. Upon presenting the theory formed in line with the understanding developed in antiquity, I accept as a functional division for the purpose of the discussion the prépon/aptum (decorum) division, i.e. into the historical and literary notion, and appropriateness as a general principle of rhetorical communication to subsequently present a discussion organised on the basis of three theses: 1) The major factor defining the rhetorical model of appropriateness is the mass nature of media communication in the presence of freedom of speech, a democratic system of authority, and economic liberalism; 2) The on-going presence of disputes regarding the appropriateness of public behaviour is a manifestation not as much of its norm-building potential as of the functional approach – of senders, participants of the reported events, and message receivers – towards media communication, which inevitably results in a distinct over-representation of messages the content of which applies to the manifestations of inappropriateness; 3) The appropriateness principle is associated with the difficult task for the receiver to understand her/his role in the world of the media, and its various consequences. I posit that the principle does, in fact, indicate certain criteria which can become a basis for classifying specific messages as those which do or do not meet the requirements of rhetorical tact, yet it does not enable one to define an a priori applicable borderline between appropriateness and inappropriateness in contemporary media. Therefore, it seems that the settlement of any doubts and dilemmas associated with appropriateness ought to be founded on a good upbringing-based social stance and a system of values, i.e. maturity achieved regardless of the influence of the media

The appropriateness of colonoscopy: a multi-center, international, observational study

AbstractObjective To examine the appropriateness and necessity of colonoscopy across Europe. Design Prospective observational study. Setting A total of 21 gastrointestinal centers from 11 countries. Participants Consecutive patients referred for colonoscopy at each center. Intervention Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy. Main outcome measure Appropriateness of colonoscopy. Results A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45-54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia [OR: 30.84, 95% CI: 19.79-48.06] or change in bowel habits [OR: 3.69, 95% CI: 2.74-4.96] were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain [OR: 0.64, 95% CI: 0.49-0.83] or chronic diarrhea [OR: 0.54, 95% CI: 0.40-0.75] were less likely to have an appropriate or necessary indication. Conclusions This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptom

Appropriateness of colorectal cancer screening: appraisal of evidence by experts

Objectives. To evaluate how the level of evidence perceived by an international panel of experts was concordant with the level of evidence found in the literature, to compare experts perceived level of evidence to their appropriateness scores, and to compare appropriateness criteria for colonoscopy between experts and an evidence-based approach. Design. Comparison of expert panel opinions and systematic literature review regarding the level of evidence and appropriateness of colonoscopy indications. Participants. European Panel on the Appropriateness of Gastrointestinal Endoscopy multidisciplinary experts from 14 European countries. Main outcome measures. Concordance and weighted kappa coefficient between level of evidence as perceived by the experts' and that found in the literature, and between panel- and literature-based appropriateness categories. Results. Experts overestimated the level of published evidence of 57 indications. Concordance between the level of evidence perceived by the experts and the actual level of evidence found in the literature was 36% (weighted kappa 0.18). Indications for colonoscopy were reported to be appropriate, uncertain, and inappropriate by the experts in 54, 19, and 27% of the cases, and by the literature in 37, 46, and 17% of the cases. A 46% agreement (weighted kappa 0.29) was found between literature-based and experts' appropriateness criteria. Conclusions. Experts often overestimated the level of evidence on which they based their decisions. However, rarely did the experts' judgement completely disagree with the literature, although concordance between panel- and literature-based appropriateness was only fair. A more explicit discussion of existing evidence should be undertaken with the experts before they evaluate appropriateness criteri

Assessing evaluation procedures for individual researchers: the case of the Italian National Scientific Qualification

The Italian National Scientific Qualification (ASN) was introduced as a prerequisite for applying for tenured associate or full professor positions at state-recognized universities. The ASN is meant to attest that an individual has reached a suitable level of scientific maturity to apply for professorship positions. A five member panel, appointed for each scientific discipline, is in charge of evaluating applicants by means of quantitative indicators of impact and productivity, and through an assessment of their research profile. Many concerns were raised on the appropriateness of the evaluation criteria, and in particular on the use of bibliometrics for the evaluation of individual researchers. Additional concerns were related to the perceived poor quality of the final evaluation reports. In this paper we assess the ASN in terms of appropriateness of the applied methodology, and the quality of the feedback provided to the applicants. We argue that the ASN is not fully compliant with the best practices for the use of bibliometric indicators for the evaluation of individual researchers; moreover, the quality of final reports varies considerably across the panels, suggesting that measures should be put in place to prevent sloppy practices in future ASN rounds

Evaluation of Prescription Appropriateness of CT Scan for Low Back Pain in Shiraz’s Referral Trauma Hospital Using RAND Appropriateness Method

Introduction: This study aims to identify the appropriateness of CT Scan prescriptions for Lumbar Spine using the RAND Appropriateness Method in Shiraz University of Medical Sciences (SUMS). Methods: A total of 281 patients referred to the hospitals affiliated with Shiraz University of Medical Sciences were selected as sample of the study in 2016. The scenarios derived through the RAND Appropriateness Method were compared with medical records of these patients by educated physicians. Results: Out of 281 cases of lumbar spine MRI prescriptions, 57.7% were appropriate, 32.7 % were uncertain, and 9.6 % were considered to be appropriate. In addition, some related factors to appropriateness of prescriptions were identified. Conclusions: Clinical guidelines developed using RAND Appropriateness Method can be an appropriate instrument for policy makers, health care providers, and health insurance companies in order to reduce inappropriate cares and quality improvement, especially in developing countries. It is recommended that appropriateness of prescriptions will be considered as the criteria for payment and reimbursement to prescribers. In this way, inappropriate cares may be reduced

Water Supply Planning under Interdependence of Actions: Theory and Application

An ongoing water supply planning problem in the Regional Municipality of Waterloo, Ontario, Canada, is studied to select the best water supply combination, within a multiple-objective framework, when actions are interdependent. The interdependencies in the problem are described and shown to be essential features. The problem is formulated as a multiple-criteria integer program with interdependent actions. Because of the large number of potential actions and the nonconvexity of the decision space, it is quite difficult to find nondominated subsets of actions. Instead, a modified goal programming technique is suggested to identify promising subsets. The appropriateness of this technique is explained, and the lessons learned in applying it to the Waterloo water supply planning problem are described

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 500clinical 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 measurer: (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 percent of comparable Indications were assigned to indentical 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 appropriatenesof medical procedures that are similar. Given the resources being invested throught the world in devilping criteria and guidelines, international collaboration in seeking optimal use of limited health care resources should be intensifled. © 1997 Elsevier Science Ltd. All rights reserve

Data Difficulties in Labor Economics

This essay sets out a framework for evaluating empirical work in terms of the ability of the data to provide adequate parameter estimates and hypothesis tests about the true underlying structure. Problems of aggregation, representativeness and structural change are discussed in detail. These criteria are applied to evaluate studies of labor supply, labor demand, local labor markets and union goals. Empirical work in labor supply has made the greatest strides because of the appropriateness of the data to answer questions of interest. Studies in the other areas have not made so much progress and will not until the same resources are devoted to collecting longitudinal microeconomic data on firms as have been spent on collecting longitudinal household data.

A multicenter study on the appropriateness of hospitalization in obstetric wards: application of Obstetric Appropriateness Evaluation Protocol (Obstetric AEP). Studio multicentrico sul protocollo di revisione dell’uso dell’ospedale in ostetricia: applicazione dello PRotocollo dell’Uso dell’Ospedale in Ostetricia (PRUO ostetrico)

Objectives This study has been based on the implementation of the Obstetric Appropriateness Evaluation Protocol in 7 Italian hospitals to determine inappropriate hospital admissions and days of stay. Design A cross-sectional study. Methods The outcomes examined were: appropriateness/inappropriateness of admission and "percentage of inappropriateness". Results A total number of 2196 clinical records were reviewed. The mean percentage of inappropriateness for a hospitalization was 22%. The percentage of inappropriateness for the first ten days of hospitalization peaked in correspondence of the 4th and 5th (42%). The emergency admission was a protective factor of inappropriated admission, OR= 0.23 95%CI (0.16-0.35). To be hospitalized in a Teaching Hospital, in a hospital with ≥30 beds and to be admitted during the Winter/Autumn and in the workweek were risk factors of inappropriateness, respectively with OR=3.50 95%CI(2.30-5.34), OR=2.04 95%CI(1.41-2.97), OR=2.14 95%CI(1.41-2.97), OR=1.85 95%CI(1.12-3.04). The linear regression model underlined that the "percentage of inappropriateness" significantly increased in inappropriate admission and in obstetric wards with ≥30 beds; the admission in a Teaching Hospital and the hospitalization in South Italy was inversely associated to the percentage of inappropriateness. The R2 model was 0.367. Conclusions The present study suggests that the percentage of inappropriate admission depends especially on the inappropriate admission and the large number of beds in obstetric wards. This suggests that the management of big hospitals, which is very complex, needs improving the processes of support and coordination of health professionals. The obstetric AEP tool seems to be an useful instrument for the decision makers to monitor and manage the obstetric wards