[Show abstract][Hide abstract] ABSTRACT: Venous thromboembolism (VTE) is a complex disorder influenced by numerous risk factors, and occurs frequently in at-risk hospitalized patients. Because appropriate prevention with thromboprophylaxis is underused, we wanted to create an electronic tool to provide a simple risk assessment and suggest appropriate prophylaxis.
To develop the risk matrix, iterative rating of odds ratios was performed for 60 predisposing VTE risk factors, using analytical methods that account for multiple risk factors in a single patient and their non-independence. For exposing risk factors, a single score was assigned to each set of factors, both medical (25 items) and surgical conditions (144 items). A CART regression model was used to integrate the risk scales into a 4-level measure of overall risk. The validity of the level of risk and the appropriateness of 11 different prophylactic approaches was assessed using the RAND/UCLA appropriateness method and validated by expert opinion ratings (n=1998) on sample case scenarios (n=108).
Correlation between the level of risk calculated by the risk matrix and that offered by expert opinion for individual surgical and medical clinical cases was high (65% and 70%, respectively). The matrix over-estimated the level of risk, compared with that offered by expert opinion, in 28% and 20% of surgical and medical cases, respectively, but the appropriate prophylaxis suggested was no different. Between-expert agreement on the appropriateness of the prophylaxis recommendations was high (90-94% of indications).
This computer-based electronic tool for individualized assessment of venous thromboembolic risk successfully identified both the perceived risk of thrombosis and the appropriate prophylactic approach for medical and surgical patients.
[Show abstract][Hide abstract] ABSTRACT: Most patients with colorectal liver metastases present to general surgeons and oncologists without a specialist interest in their management. Since treatment strategy is frequently dependent on the response to earlier treatments, our aim was to create a therapeutic decision model identifying appropriate procedure sequences.
We used the RAND Corporation/University of California, Los Angeles Appropriateness Method (RAM) assessing strategies of resection, local ablation and chemotherapy. After a comprehensive literature review, an expert panel rated appropriateness of each treatment option for a total of 1,872 ratings decisions in 252 cases. A decision model was constructed, consensus measured and results validated using 48 virtual cases, and 34 real cases with known outcomes.
Consensus was achieved with overall agreement rates of 93.4 to 99.1%. Absolute resection contraindications included unresectable extrahepatic disease, more than 70% liver involvement, liver failure, and being surgically unfit. Factors not influencing treatment strategy were age, primary tumor stage, timing of metastases detection, past blood transfusion, liver resection type, pre-resection carcinoembryonic antigen (CEA), and previous hepatectomy. Immediate resection was appropriate with adequate radiologically-defined resection margins and no portal adenopathy; other factors included presence of < or = 4 or > 4 metastases and unilobar or bilobar involvement. Resection was appropriate postchemotherapy, independent of tumor response in the case of < or = 4 metastases and unilobar liver involvement. Resection was appropriate only for > 4 metastases or bilobar liver involvement, after tumor shrinkage with chemotherapy. When possible, resection was preferred to local ablation.
The results were incorporated into a decision matrix, creating a computer program (OncoSurge). This model identifies individual patient resectability, recommending optimal treatment strategies. It may also be used for medical education.
Journal of Clinical Oncology 10/2005; 23(28):7125-34. · 17.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Scenarios alert policymakers and stakeholders to emerging problems and provide a reference point for long-term strategic planning. To be useful, scenarios have to be both scientifically credible and policy-relevant. A wide range of perceptions have to be taken into account in the scenario-building process – as policymaking is not or no longer characterised by 'the choice' of 'the policymaker' and policymaking processes have become more and more open. The question is how to deal with divergent perceptions and interests. The traditional scenario approach does not address these issues – it was originally designed for authorative top-down planning. In this paper, we explore, based on two case studies, what demands a multi-actor policy setting puts on the scenario-building process.
International Journal of Technology Policy and Management 01/2005; 5(2).
[Show abstract][Hide abstract] ABSTRACT: Clinical practice guidelines quickly become outdated. One reason they might not be updated as often as needed is the expense of collecting expert judgment regarding the evidence. The RAND-UCLA Appropriateness Method is one commonly used method for collecting expert opinion. We tested whether a less expensive, mail-only process could substitute for the standard in-person process normally used.
We performed a 4-way replication of the appropriateness panel process for coronary revascularization and hysterectomy, conducting 3 panels using the conventional in-person method and 1 panel entirely by mail. All indications were classified as inappropriate or not (to evaluate overuse), and coronary revascularization indications were classified as necessary or not (to evaluate underuse). Kappa statistics were calculated for the comparison in ratings from the 2 methods.
Agreement beyond chance between the 2 panel methods ranged from moderate to substantial. The kappa statistic to detect overuse was 0.57 for coronary revascularization and 0.70 for hysterectomy. The kappa statistic to detect coronary revascularization underuse was 0.76. There were no cases in which coronary revascularization was considered inappropriate by 1 method, but necessary or appropriate by the other. Three of 636 (0.5%) hysterectomy cases were categorized as inappropriate by 1 method but appropriate by the other.
The reproducibility of the overuse and underuse assessments from the mail-only compared with the conventional in-person conduct of expert panels in this application was similar to the underlying reproducibility of the process. This suggests a potential role for updating guidelines using an expert judgment process conducted entirely through the mail.
Medical Care 01/2004; 41(12):1374-81. · 2.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the appropriateness of and variation in intention-to-treat decisions in the management of depression in the Netherlands.
Mailed survey with 22 paper cases (vignettes) based on a population study.
A random sample from four professional groups in the Dutch mental healthcare system.
264 general practitioners, psychiatrists, psychotherapists, and clinical psychologists.
Each vignette contained information on a number of patient characteristics taken from three national depression guidelines. The distribution of patient characteristics was based on data from a population study. Respondents were asked to choose the best treatment option and the best treatment setting. For each vignette we examined which of the selected treatments was appropriate according to the recommendations of the three published Dutch clinical guidelines and a panel of experts.
31% of all intention-to-treat decisions were not consistent with the guidelines. Overall, less severe depression, alcohol abuse, psychotic features, and lack of social resources were related to more inappropriate judgements. There was considerable variation between the professional groups: psychiatrists made more appropriate choices than the other professions although they had the highest rate of overtreatment.
There is sufficient variation in the intentions to treat depression to give it priority in quality assessment and guideline development. Efforts to achieve appropriate care should focus on treatment indications, referral patterns, and overtreatment.
Quality and Safety in Health Care 10/2002; 11(3):214-8. · 2.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Drug use is an increasing problem in Portugal. In response, following the advice of a select committee, the Portuguese government has recently issued a number of laws implementing a strong harm-reductionistic orientation. The flagship of these laws is the decriminalization of the use and possession for use of drugs. Use and possession for use are now only administrative offenses; no distinction is made between different types of drugs (hard vs. soft drugs) or whether consumption is private or in public. Although most people favor decriminalization in principle, doubts have been expressed about the way the law will be implemented because the law only sets a framework for those communities that wish to undertake such activities--it is an enabling law. This has led to a considerable lack of clarity and increases the risk of dissimilarity of implementation in different parts of the country. The future will show the effects.
The Annals of the American Academy of Political and Social Science 07/2002; 582(1):49-63. · 1.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study deals with pharmacotherapeutical issues in pediatrics. The overall impression is that large lacunae exist in research on the pharmacological treatment of children. Most drugs are not studied in a pediatrics population before market introduction, while there are several important differences in drug use and effects between adults and children. Examples -include: - Medication efficacy and safety has usually been tested on adults, but effects are unknown with children as subjects. Pediatric clinical trials are subject to many restrictions (ethics, practical guidelines) - Differences in distribution and elimination of drugs between adults and children, and lack of knowledge about pharmacokinetics and -dynamics - Differences in dose, frequency and route of administration - Differences in compliance and non-compliance - Differences in (tracking of) side effects and adverse reactions due to medications. The Dutch Health Care Insurance Board (abbreviated CVZ for its Dutch name) recognizes the need for research on medications in children. It has issued a study, to be conducted by RAND Europe, to prioritize medications for clinical research in children. The need for researching the use of medication by children has several aspects and involves the expertise of different medical professionals. This project focuses on the following questions: - To what extent do medical professionals face and recognize problems concerning the use of medication by children? - Which concerns exist among these professionals regarding the use of medication by children? - How can these concerns be translated into priorities for research? - Which Organizational structure is needed to give direction to future research? The literature review serves as an inventory to areas of discussion and controversy in the main disease fields of pediatrics.
[Show abstract][Hide abstract] ABSTRACT: We convened a multinational panel to develop appropriateness criteria for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG). To assess the applicability of these criteria, we applied them to patients referred for coronary revascularization. Finally, to understand how multinational criteria may differ from criteria developed by a panel of physicians from one country, we compared the appropriateness ratings using the multinational panel's criteria and those made using similar criteria previously developed by a panel of Dutch physicians.
We conducted a prospective survey and review of the medical records of 2363 consecutive patients presenting with chronic stable angina or following a myocardial infarction who were referred for PTCA (n=1137) or CABG (n= 1226) at ten Dutch hospitals performing coronary revascularization. Appropriateness was measured using two sets of criteria developed by: (1) a Dutch panel of cardiologists and cardiothoracic surgeons in 1991; and (2) a similarly composed European panel in 1998.
More PTCA referrals were rated inappropriate by Dutch criteria compared with multinational criteria among both patients with chronic stable angina (34.8 versus 6.1%; P< 0.001) and those with a recent myocardial infarction (28.1 versus 0.9%; P< 0.001). Among those patients referred for bypass surgery, the Dutch criteria judged a greater proportion of cases inappropriate than multinational criteria did for patients with chronic stable angina (3.7 versus 1.5%, P< 0.001). The proportion of cases rated inappropriate for bypass surgery among patients following a myocardial infarction was similar between the two panels (3.9 versus 2.4%, respectively; P=0.40). After reclassifying the data for two of the clinical factors used in the appropriateness criteria (lesion morphology and intensity of medical therapy) based on evidence that appeared in the literature after the Dutch panel met, we found no significant differences between the Dutch and multinational panels' appropriateness ratings.
While fewer cases were judged inappropriate using the multinational criteria compared with the Dutch criteria, the differences in ratings were related primarily to the clinical factors used by each panel. These findings support the review of appropriateness criteria, and other forms of clinical guidelines, to ensure that they are current with the clinical evidence before using them to assess clinical care. Developing such criteria using a multinational panel, in contrast to multiple single country panels, would be a more efficient use of resources.
International Journal for Quality in Health Care 05/2002; 14(2):103-9. · 1.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Journal of Clinical Epidemiology 11/2001; 54(10):1004-10. · 5.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Over the last decade, a number of organisations have developed clinical guidelines, typically at a national level, in order to increase appropriate health care. This raises the question as to whether it is possible to develop guidelines, applicable on the national level, at an international level. In order to examine this, we compared the appropriateness criteria for the treatment of benign prostatic hyperplasia ratings developed by two panels, one a single-nationality (Dutch) panel, the other a multinational (European) panel. The panels, both consisting of experienced urologists, used a modified Delphi process to rate 1152 indications for the most common treatments (surgery, alpha-blocker, finasteride and watchful waiting) on a nine-point scale. This article describes the similarities and differences between the ratings produced by the panels. The appropriateness ratings were identical for 84% of the indications (kappa=0.76). The difference in the scores for individual indications was zero in 41% of indications and less than or equal to two in 99% of indications. This study provides strong evidence that a multinational panel can deliver essentially the same appropriateness ratings for BPH as a national panel. Developing appropriateness criteria on an international level may result in significant savings and may help contribute to the reduction of undesirable practice variation.
Health Policy 08/2001; 57(1):45-56. · 1.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
To identify the degree to which appropriateness ratings for coronary revascularization developed by a multinational panel differ by panelist specialty and nationality.
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.
Mean appropriateness ratings by panelist specialty and nationality.
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.
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.
Medical Care 06/2001; 39(5):513-20. · 2.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To perform a systematic analysis of clinical expertise on treatment for benign prostatic hyperplasia (lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO)) and to investigate the usefulness of these data in further guideline development.
A modified Delphi method was used to analyse the opinions of a panel of 15 European urologists on the appropriateness of 4 common treatments for 1,152 "indications" (hypothetical cases) for LUTS suggestive of BPO. Each indication consisted of a unique combination of 9 diagnostic variables, found to be relevant in treatment choice in previous research. The study population was restricted to patients for whom current guidelines do not provide clear indications on the most appropriate treatment. The panellists individually rated the appropriateness of three active treatments (surgery, alpha(1)-adrenoceptor antagonists, finasteride) using a 9-point scale, all in comparison with "watchful waiting". Aggregate panel judgements were calculated from individual ratings for each indication (appropriate, inappropriate, and uncertain). The relationship between diagnostic characteristics and panel opinions was analysed using logistic regression methods. The results were compared to those of an identical panel study including 12 Dutch urologists.
Strong agreement existed for 42.5% of the indications, while strong disagreement was found in only 0.1%. For patients who had not previously been treated for LUTS, surgery was considered appropriate in 44% of the indications. For alpha(1)-adrenoceptor antagonists and finasteride these percentages were 56 and 6 respectively. Strong contra-indications were found only for finasteride (34%). Logistic regression analysis demonstrated consistent panel opinions, indicating a strong cumulative impact of almost all diagnostic variables on the panel judgement "appropriate". The figures on appropriateness were highly comparable to the results of the Dutch study (overall agreement 84%, kappa 0,76). A computer program was constructed to facilitate the implementation and evaluation of the panel recommendations in daily clinical practice.
Given the consistency of the panel opinions, the results may be useful in complementing evidence-based guidelines for LUTS suggestive of BPO in the grey area of treatment choice.
European Urology 02/2001; 39 Suppl 3:13-9. · 12.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
European Journal of Cardio-Thoracic Surgery 11/2000; 18(4):380-7. · 2.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
International Journal of Technology Assessment in Health Care 02/2000; 16(1):190-8. · 1.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the overuse and underuse of medical procedures, various methods have been developed, but their reproducibility has not been evaluated. This study estimates the reproducibility of one commonly used method.
We performed a parallel, three-way replication of the RAND-University of California at Los Angeles appropriateness method as applied to two medical procedures, coronary revascularization and hysterectomy. Three nine-member multidisciplinary panels of experts were composed for each procedure by stratified random sampling from a list of experts nominated by the relevant specialty societies. Each panel independently rated the same set of clinical scenarios in terms of the appropriateness of the relevant procedure on a risk-benefit scale ranging from 1 to 9. Final ratings were used to classify the procedure in each scenario as necessary or not necessary (to evaluate underuse) and inappropriate or not inappropriate (to evaluate overuse). Reproducibility was measured by overall agreement and by the kappa statistic. The criteria for underuse and overuse derived from these ratings were then applied to real populations of patients who had undergone coronary revascularization or hysterectomy.
The rates of agreement among the three coronary-revascularization panels were 95, 94, and 96 percent for inappropriate-use scenarios and 93, 92, and 92 percent for necessary-use scenarios. Agreement among the three hysterectomy panels was 88, 70, and 74 percent for inappropriate-use scenarios. Scenarios involving necessary use of hysterectomy were not assessed. The three-way kappa statistic to detect overuse was 0.52 for coronary revascularization and 0.51 for hysterectomy. The three-way kappa statistic to detect underuse of coronary revascularization was 0.83. Application of individual panels' criteria to real populations of patients resulted in a 100 percent variation in the proportion of cases classified as inappropriate and a 20 percent variation in the proportion of cases classified as necessary.
The appropriateness method is far from perfect. Appropriateness criteria may be useful in comparing levels of appropriate procedures among populations but should not by themselves be used to direct care for individual patients.
New England Journal of Medicine 07/1998; 338(26):1888-95. · 54.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the clinical consistency of expert panelists' ratings of appropriateness for coronary artery bypass surgery.
Quantitative analysis of panelists' ratings.
Nine physicians (three cardiothoracic surgeons, four cardiologists, and two internists) convened by RAND to establish criteria for the appropriateness of coronary artery bypass surgery.
Percentage of indication-pairs given clinically inconsistent ratings (i.e. higher rating assigned to one member of an indication-pair when rating should have been equal or lower).
In the final round of appropriateness ratings, among 1785 pairs of indications differing only on a single clinical factor (e.g., three-vessel vs. two-vessel stenosis), 6.6% were assigned clinically inconsistent ratings by individual panelists, but only 2.7% received inconsistent ratings from the panel as a whole (using the median panel rating as the criterion). Internists on the panel provided fewer inconsistent ratings (4.6%) than either cardiologists (7.8%) or cardiothoracic surgeons (6.3%) (p < 0.001). More inconsistencies were noted when the factor distinguishing otherwise identical indications was symptom severity (inconsistency rate, 13.2%) or intensity of medical therapy (13.2%) than when it was number of stenosed vessels (3.8%) or proximal left anterior descending (PLAD) involvement (1.9%). Contrary to expectations, panelists' inconsistency rates increased between the initial and final rounds of appropriateness ratings (from 3.9 to 6.6%, p < 0.001). Panelists' mean ratings across indications were only weakly correlated with individual inconsistency rates (r = 0.18, p = ns).
The RAND/UCLA method for assessing the appropriateness of coronary revascularization generally produces criteria that are clinically consistent. However, research is needed to understand the sources of panelists' inconsistencies and to reduce inconsistency rates further.
Health Policy 12/1997; 42(2):135-43. · 1.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies.
We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery.
The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels' rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.
Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons' rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties.
statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies.
Health Policy 11/1997; 42(1):67-81. · 1.73 Impact Factor