David H. Solomon

Variations in the Use of Medical and Surgical Services By the Medicare Population

We measured geographic differences in the use of medical and surgical services during 1981 by Medicare beneficiaries (age greater than or equal to 65) in 13 large areas of the United States. The average number of Medicare beneficiaries per site was 340,000. We found large and significant differences in the use of services provided by all medical and surgical specialties. Of 123 procedures studied, 67 showed at least threefold differences between sites with the highest and lowest rates of use. Use rates were not consistently high in one site, but rates for procedures used to diagnose and treat a specific disease varied together, as did alternative treatments for the same condition. These results cannot be explained by the actions of a small number of physicians. We do not know whether physicians in high-use areas performed too many procedures, whether physicians in low-use areas performed too few, or whether neither or both of these explanations are accurate. However, we do know that the differences are too large to ignore and that unless they are understood at a clinical level, uninformed policy decisions that have adverse effects on the health of the elderly may be made.

The Appropriateness of Carotid Endarterectomy

Abstract Carotid endarterectomy is a commonly performed but controversial procedure. We developed from the literature a list of 864 possible reasons for performing carotid endarterectomy, and asked a panel of nationally known experts to rate the appropriateness of each indication using a modified Delphi technique. On the basis of the panels ratings, we determined the appropriateness of carotid endarterectomy in a random sample of 1302 Medicare patients in three geographic areas who had had the procedure in 1981. Thirty-five percent of the patients in our sample had carotid endarterectomy for appropriate reasons, 32 percent for equivocal reasons, and 32 percent for inappropriate reasons. Of the patients having inappropriate surgery, 48 percent had less than 50 percent stenosis of the carotid artery that was operated on. Fifty-four percent of all the procedures were performed in patients without transient ischemic attacks in the carotid distribution. Of these procedures, 18 percent were judged appropriate,...

Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures

We convened three panels of physicians to rate the appropriateness of a large number of indications for performing a total of six medical and surgical procedures. The panels followed a modified Delphi process. Panelists separately assigned initial ratings, then met in Santa Monica, California where they received reports showing their initial ratings and the distribution of the other panelists ratings. They discussed the indications and revised the indications lists, then individually assigned final ratings. There was generally better agreement on the final ratings than on the initial ratings. Based on reasonable criteria for agreement and disagreement, and excluding one outlying procedure, the panelists agreed on ratings for 42 to 56 per cent of the indications, and disagreed on 11 to 29 per cent.

The Thyroid Nodule

Abstract The various techniques for evaluating a thyroid nodule are described and their relative values analyzed. Fine-needle aspiration is the most sensitive and specific test among the leading te...

Predicting the Appropriate Use of Carotid Endarterectomy, Upper Gastrointestinal Endoscopy, and Coronary Angiography

BACKGROUND AND METHODS In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately. RESULTS In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01). CONCLUSIONS Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.

Hypogonadism and mineralocorticoid excess. The 17-hydroxylase deficiency syndrome.

VARIOUS inherited defects in adrenal steroidogenesis have been described and carefully studied. The best known examples involve deficiencies in 21 and 11β-hydroxylation, which are necessary steps i...

Short- and Long-Term Residents of Nursing Homes

This article analyzes reported data on length of stay of discharged patients from the 1977 National Nursing Home Survey. Assuming that patients admitted to nursing homes are one of two types, short-stayers and long-stayers, the statistically best-fitting proportions and expected lengths of stay for the two types are derived. The results are applied to statistics on characteristics of resident and discharged patients to find admission characteristics that differentiate the two groups. Because long-stayers and short-stayers have quite different characteristics, nursing home statistics will be very different if one bases them on discharges or a cross-section of residents. For example, we estimate that short-stay patients represent 61 per cent of discharges but only 9 per cent of residents. A further application shows that, including deaths in hospitals, almost half of discharged patients die, rather than the usually cited figure of 25 per cent.

The Use and Misuse of Upper Gastrointestinal Endoscopy

STUDY OBJECTIVE To determine how appropriately physicians in 1981 did upper gastrointestinal endoscopy in a randomly selected, community-based sample of Medicare patients. DESIGN We developed a comprehensive and clinically detailed list of 1069 indications for upper gastrointestinal endoscopy. A national panel of nine clinicians rated the appropriateness of the indications. We categorized the indications as appropriate, inappropriate, or equivocal. We did a clinically detailed medical record review of a random sample of 1585 patients having upper gastrointestinal endoscopy to assess the appropriateness of using upper gastrointestinal endoscopy. SETTING Patients were sampled from large geographic areas in three states. Two areas represented high use, and one area, low use. PATIENTS Random sample of patients 65 years of age or older receiving diagnostic upper gastrointestinal endoscopy. INTERVENTIONS None; the study was retrospective. MEASUREMENT AND RESULTS Patient characteristics, histories, and clinical indications for upper gastrointestinal endoscopy were similar across low- and high-use areas. Overall, 72% of the endoscopies were done for appropriate indications, 11% for equivocal indications, and 17% for inappropriate indications. Upper gastrointestinal bleeding (26%), follow-up to an abnormal upper gastrointestinal series (21%), dysphagia (18%), and dyspepsia (15%) were the most frequent clinical reasons for doing endoscopy. Inpatient endoscopies were more often appropriate and less often inappropriate than outpatient endoscopies. CONCLUSIONS This analysis of practice patterns among study sites provides the clinical basis for understanding the use of upper gastrointestinal endoscopy. The finding of 17% inappropriate use may be cause for concern.

Carotid Endarterectomy for Elderly Patients: Predicting Complications

OBJECTIVE To determine whether the complication or death rate from carotid endarterectomy can be predicted from hospital and physician structural variables, such as the hospitals teaching status or the number of endarterectomies done by the surgeon per year. DESIGN Survey of medical records. After controlling for the severity of the patients condition on the basis of data in the medical record at the time of the endarterectomy, regression analyses were used to predict the postoperative stroke, heart attack, and 30-day death rate as a function of patient, physician, and hospital characteristics. SETTING Three geographic areas (states or large parts of states; average population, 3 million) in the United States. PATIENTS Random sample of 1302 patients 65 years of age or older having carotid endarterectomy in 1981. INTERVENTION Carotid endarterectomy. MEASUREMENTS AND MAIN RESULTS Of 1302 patients, 11.3% had a postoperative stroke or heart attack or died within 30 days of the operation. Patient age, race, income, and gender; physician volume, board certification status, and age; and hospital size, for-profit status, ownership, and teaching status were not significantly related to the postoperative complication or death rate. If the surgeon was a graduate of a foreign, but not a Western European or Canadian, medical school, however, the average complication or death rate rose from 10.4% to 19.6% (P less than 0.05). CONCLUSIONS The effectiveness of carotid endarterectomy depends heavily on its complication rate. Because complications after surgery cannot, in general, be predicted from structural variables, referring physicians cannot rely solely on the surgeons experience and qualifications when recommending a carotid endarterectomy. The surgeons and the hospitals actual postoperative complication and death rate should be considered.

Relation Between Surgeons' Practice Volumes and Geographic Variation in the Rate of Carotid Endarterectomy

We examined the relation between the number of operative procedures carried out by individual surgeons and the variation in the rate of carotid endarterectomy among Medicare beneficiaries in areas of high, average, and low use of the procedure in 1981. Rates ranged from 48 per 100,000 in the low-use area to 178 per 100,000 in the high-use area. Two variables accounted for most of the differences in the rates: the number of surgeons performing the procedure and the number of endarterectomies performed by surgeons with high practice volumes. Twice as many surgeons in the high-use area and 25 percent more in the average-use area performed carotid endarterectomy as compared with those in the low-use area. If the average number of cases per surgeon had been the same, the differences in the number of surgeons would have accounted for 36 percent and 15 percent, respectively, of the differences in use. Surgeons who performed 15 or more carotid endarterectomies during the year accounted for most of the variation in the rates. These high-volume surgeons represented 15 percent and 17 percent of the surgeons in the areas of high and average use, respectively, as compared with 4 percent of those in the low-use area. They accounted for 60 and 77 percent, respectively, of the additional endarterectomies. Three fourths of the surgeons performing carotid endarterectomies carried out fewer than 10, and 24 percent did only 1. We conclude that most of the geographic variation in the rate of carotid endarterectomy is caused by a few surgeons in high-use areas who perform large numbers of operations.