PubMed Health⌕ Search

Biomedical subjects

I Pache

Publications and source records attributed to I Pache.

7 recordsLinked to original sources
PubMed1998

Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study.

BACKGROUND: Prospective data describing the appropriateness of use of colonoscopy based on detailed panel-based clinical criteria are not available. METHODS: In a cohort of 553 consecutive patients referred for colonoscopy to two university-based Swiss outpatient clinics, the percentage of patients who underwent colonoscopy for appropriate, equivocal, and inappropriate indications and the relationship between appropriateness of use and the presence of relevant endoscopic lesions was prospectively assessed. This assessment was based on criteria of the American Society for Gastrointestinal Endoscopy and explicit American and Swiss criteria developed in 1994 by a formal panel process using the RAND/UCLA appropriateness method. RESULTS: The procedures were rated appropriate or equivocal in 72.2% by criteria of the American Society for Gastrointestinal Endoscopy, in 68.5% by explicit American criteria, and in 74.4% by explicit Swiss criteria (not statistically significant, NS). Inappropriate use (overuse) of colonoscopy was found in 27.8%, 31.5%, and 25.6%, respectively (NS). The proportion of appropriate procedures was higher with increasing age. Almost all reasons for using colonoscopy could be assessed by the two explicit criteria sets, whereas 28.4% of reasons for using colonoscopy could not be evaluated by the criteria of the American Society for Gastrointestinal Endoscopy (p < 0.0001). The probability of finding a relevant endoscopic lesion was distinctly higher in the procedures rated appropriate or equivocal than in procedures judged inappropriate. CONCLUSIONS: The rate of inappropriate use of colonoscopy is substantial in Switzerland. Explicit criteria allow assessment of almost all indications encountered in clinical practice. In this study, all sets of appropriateness criteria significantly enhanced the probability of finding a relevant endoscopic lesion during colonoscopy.

Algorithms↗
PubMed1998

Reliability of panel-based guidelines for colonoscopy: an international comparison.

BACKGROUND: This study examined the reliability of explicit guidelines developed using the RAND-UCLA appropriateness method. METHODS: The appropriateness of over 400 indications for colonoscopy was rated by two multispecialty expert panels (United States and Switzerland). A nine-point scale was used, which was consolidated into three categories of appropriateness: appropriate, uncertain, inappropriate. The distribution of appropriateness ratings between the two panels and the intrapanel and interpanel agreement for categories of appropriateness were calculated for all possible indications. Similar statistics were calculated for a series of 577 primary care patients referred for colonoscopy in Switzerland. RESULTS: Over 80% of all indications (348) could be directly compared. The proportions of indications classified as appropriate, uncertain, or inappropriate were 28.4%, 24.7%, 46.6% and 33.0%, 23.0%, 44.0% for the U.S. and the Swiss panels, respectively. Interpanel agreement was excellent for all the possible indications (kappa value: 0.75) and lower for actual cases (kappa value: 0.51) because of lower agreement for the most frequently encountered indications. CONCLUSIONS: Good agreement between the two sets of criteria was found, pointing to the reliability of the method. Partial disagreement occurred essentially for a few, albeit frequently encountered, indications for use of colonoscopy in cases of uncomplicated lower abdominal pain or constipation.

Colonoscopy↗
PubMed1997

Underutilization of upper gastrointestinal endoscopy.

BACKGROUND & AIMS: Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy. METHODS: Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic. RESULTS: During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients. CONCLUSIONS: This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.

Adolescent↗
PubMed1997

Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care.

BACKGROUND: This prospective observational study was aimed at evaluating the appropriateness of use of upper gastrointestinal endoscopy (UGE) in primary care in a country with open access to and high availability of the procedure. METHODS: Outpatients were consecutively included in two clinical settings: Setting A (20 primary care physicians during 4 weeks) and B (university-based outpatient clinic during 3 weeks). In patients undergoing UGE, appropriateness of referral was judged by explicit Swiss criteria developed by the RAND/UCLA panel method. RESULTS: Patient visits (8135) were assessed. Six hundred eleven patients complained of upper gastrointestinal symptoms. Physicians decided to perform UGE in 63 of these patients. Twenty-five (40%) of the endoscopies were rated appropriate, 7 (11%) equivocal, and 31 (49%) inappropriate. Overuse of UGE occurred in 5.1% (setting A: 4.7%; setting B:6.5%; p = 0.39) of the patients who presented with upper gastrointestinal symptoms. The decision to perform UGE in previously untreated dyspeptic patients was the most common clinical situation resulting in overuse. CONCLUSIONS: Inappropriate use of UGE is high in Switzerland. However, to better reflect primary care decision making, overuse should be related not only to patients referred for a medical test, but also to the number of patients who complain of the symptoms that would be investigated by the procedure.

Adolescent↗
PubMed1997

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 500 clinical 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 MEASURES: (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 per cent of comparable indications were assigned to identical 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 appropriateness of medical procedures that are similar. Given the resources being invested throughout the world in developing criteria and guidelines, international collaboration in seeking optimal use of limited health care resources should be intensified.

Endoscopy, Gastrointestinal↗
PubMed1996

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy unit.

BACKGROUND AND STUDY AIMS: This prospective study tested the appropriateness of referrals for upper gastrointestinal endoscopy in an open-access endoscopy unit, using the criteria of the American Society for Gastrointestinal Endoscopy. It also examined whether there was any relationship between appropriateness of use and the presence of significant lesions detected by endoscopy. METHODS: Four hundred fifty consecutive upper gastrointestinal endoscopies were studied prospectively. The referral indication was recorded by the endoscopist before the procedure was performed, and was compared with the current criteria of the American Society for Gastrointestinal Endoscopy and with endoscopic findings. RESULTS: The appropriateness of referral was assessed in 442 consecutive endoscopies. Of these, 252 (57%) were judged to be appropriate. In 168 (88%) of the 190 endoscopies rated as inappropriate, the reason was that the patient had not undergone empirical anti-ulcer therapy before endoscopy. The probability of finding a significant lesion did not differ between the endoscopies judged to be appropriate (50%) and those judged to be inappropriate (46%) CONCLUSIONS: Upper gastrointestinal endoscopy was frequently used for inappropriate indications. The main reason for inappropriate use was insufficient treatment, or no treatment, of dyspeptic symptoms prior to endoscopy. In this study, the criteria for appropriateness did not predict the probability of finding a significant endoscopic lesion.

Adult↗