Appropriateness Criteria to Assess Variations in Surgical Procedure Use in the United States

Objectives: To systematically describe appropriateness criteria (AC) developed in the United States for surgical procedures and to summarize how these criteria have been applied to identify overuse and underuse of procedures in US populations. Data Sources: MEDLINE literature search performed in February 2010 and May 2011. Study Selection: Studies were included if they addressed the appropriateness of a surgical procedure using the RAND-UCLA Appropriateness Method. Non-US studies were excluded. Data Extraction: Information was abstracted on study design, surgical procedure, and reported rates of appropriate use, overuse, and underuse. Identified AC were cross-referenced with lists of common procedures from the Nationwide Inpatient Sample and the State Ambulatory Surgery databases. Data Synthesis: A total of 1601 titles were identified; 39 met the inclusion criteria. Of these, 17 developed AC and 27 applied AC to US populations. Appropriateness criteria have been developed for 16 surgical procedures. Underuse has only been studied for coronary artery bypass graft surgery, and rates range from 24% to 57%. Overuse has been more broadly studied, with rates ranging from 9% to 53% for carotid endarterectomy, 0% to 14% for coronary artery bypass graft, 11% to 24% for upper gastrointestinal tract endoscopy, and 16% to 70% for hysterectomy. Appropriateness criteria exist for 10 of the 25 most common inpatient procedures and 6 of the 15 top ambulatory procedures in the United States. Most studies are more than 5 years old. Conclusions: Most existing AC are outdated, and AC have never been developed for most common surgical procedures. A broad and coordinated effort to develop and maintain AC would be required to implement this tool to address variation in the use of surgical procedures.