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Objectives: This report is a scoping review of the literature with the objective of identifying definitions, conceptual models and frameworks, as well as the methods and range of perspectives, for determining appropriateness in the context of healthcare delivery.
Methods: To lay groundwork for future, intervention-specific research on appropriateness, this work was carried out as a scoping review of published literature since 1966. Two reviewers, with two screens using inclusion/exclusion criteria based on the objective, focused the research and articles chosen for review.
Results: The first screen examined 2,829 abstracts/titles, with the second screen examining 124 full articles, leaving 37 articles deemed highly relevant for data extraction and interpretation. Appropriateness is defined largely in terms of net clinical benefit to the average patient and varies by service and setting. The most widely used method to assess appropriateness of healthcare services is the RAND/UCLA Model. There are many related concepts such as medical necessity and small-areas variation.
Conclusions: A broader approach to determining appropriateness for healthcare interventions is possible and would involve clinical, patient and societal perspectives.
Cataract surgery is the highest-volume surgical procedure in Canada, with over 200,000 performed annually, mostly (85%) on persons aged 65 or older. Concerns have been raised about wait times to access this procedure. This study explores the relationship between waiting times for cataract surgery in Manitoba and a variety of characteristics, including age, sex, socio-economic status, region of residence, health status, surgeon, and surgeon's caseload. The study included 6,114 individuals who had first-eye cataract surgery between November 1, 1998, and March 31, 2000, in Winnipeg, MB. Significant predictors of variation in wait times were age, sex, having a hospitalization while waiting, and surgeon. The model explained 32.5 per cent of the variance in wait times; specific surgeon independently explained 29.5 per cent of the variance. Median waiting times varied widely by surgeon, ranging from 61 to 399 days. Differences in surgeons' expected wait times should be available to patients and referring clinicians.
The effects of long-term hospitalizations can be severe, especially among older adults. In Manitoba, between fiscal years 1991/1992 and 1999/2000, 40 per cent of acute care hospital days were used by the 5 per cent of patients who had long stays, defined as stays of more than 30 days. These proportions were remarkably stable, despite major changes in the bed supply. Approximately two thirds of long-stay patients were aged 75 or older. Medical record review for a small sample of long-stay medical patients aged 75 or older revealed that 42 per cent of the days spent in hospital were spent either awaiting transfer to another level of care (home care, nursing home, or chronic care), or were due to in-hospital factors, such as awaiting consults, tests, or treatments. Hospital information systems and early discharge planning may help to alleviate lengthy discharge delays and result in better care for these patients.
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