Appropriate and Necessary

Dear Editor:

I congratulate you on the publication of the article Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method.¹ This paper had been published by the Spanish Ministry of Health in its series “Reports, Studies and Research, 2009: standards for appropriate use of healthcare technologies”,² which also included the analysis of cholelithiasis and choledocholithiasis as well as laparoscopic liver surgery using the RAND/UCLA method. I hope that in future issues of your journal the authors will publish the analyses of the other pathologies included in the report. Although I do not consider myself a professional in this area, I would like to make some comments regarding the RAND/UCLA method that may be of use for non-experts in this method for assessing technologies.

• 1.

  Why this method? Problem: the wide variability seen in the application of a procedure (diagnosis, treatment, etc.) among different physicians, hospitals, regions, countries, etc. is not due to differential characteristics of the patients but instead to doctors’ preferences, culture, setting, etc., which could lead to correct or incorrect utilization (under- or overutilization of resources). In this latter case, we would find ourselves in a situation of inequality in the application of the resources necessary for patients: some patients receive unnecessary procedures that could benefit others that do not receive them. It is estimated that one-third of the healthcare system budget is used for services that provide little or no benefit. In short, it is possible that the variability indicates inappropriate use of medical procedures.

• 2.

  Definition of inappropriate medical procedure: according to JENNET,³ any procedure that is unnecessary (the same objective could be met with simpler means), useless (the patient is not going to respond to the procedure applied), unsafe, meaningless (uses resources that could be destined for other more beneficial activities) or merciless (does not offer a good quality of life).

• 3.

  Why the RAND/UCLA? in order to know in what specific clinical circumstances the application of a medical procedure is appropriate, inappropriate or uncertain. Very specific standards are established that are able to classify the patients in detail (classify all the patients) and mutually exclusive (the patient can only be classified in one category), in such a way that the list of indications can contain hundreds or thousands of categories.

• 4.

  Applications of the RAND/UCLA: to evaluate whether the patients treated by a doctor, department, hospital, etc. have been treated appropriately, inappropriately or whether there was some uncertainty. It is a retrospective application, and if it reveals that there is a high proportion of inappropriate use, the causes would have to be investigated: lack of guidelines, lack of quality control, etc. It can also be applied prospectively to verify whether the procedure is being used correctly.

• 5.

  Weak points of the RAND/UCLA: (1) the selection of the panel of experts may not be adequate in number (a minimum of 9 is recommended) and/or in experience or motivation because the process takes months. It needs to be a multidisciplinary team that represents different regions and hospitals, without conflicts of interest, etc. It is easy to assume that if the panel is constituted by a majority that favors a new procedure (without sufficient evaluation) that is on the cutting edge of modernity or with interests in private medicine, there may be an inclination toward indicating the particular procedure; (2) the process is long and costly, with a possible loss of participants; (3) the evidence on which the recommendations are based is limited: would a different panel make different recommendations? Several studies have demonstrated the validity and reproducibility of the method.

Last of all, another step in the evaluation of healthcare procedures should be to define from among the adequate procedures those that are actually necessary. When a person perceives a health problem, he/she may or may not seek medical assistance. Furthermore, not all problems are perceived and even very mild discomfort may be due to a serious disease. This means that not all patients who need medical attention seek it, and not all patients who seek medical attention actually need it. Thus, the problem arises from the difficulty of being able to define what is necessary. Simply put (and there is much debate in this regard) necessary procedures are those that are considered appropriate, and not performing them would be medical malpractice (but, is open cholecystectomy malpractice, and laparoscopic cholecystectomy a necessary procedure?). In order to calculate the need and establish criteria for this need, the extended RAND/UCLA is used with a third Delphi round in which the expert panel only scores the indications that are previously qualified as appropriate.