Search tips
Search criteria 


Logo of cmajCMAJ Information for AuthorsCMAJ Home Page
CMAJ. 1996 February 1; 154(3): 321–328.
PMCID: PMC1487507

Appropriateness in health care delivery: definitions, measurement and policy implications.


A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.

Full text

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (2.3M), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53–63. [PubMed]
  • Park RE, Fink A, Brook RH, Chassin MR, Kahn KL, Merrick NJ, Kosecoff J, Solomon DH. Physician ratings of appropriate indications for six medical and surgical procedures. Am J Public Health. 1986 Jul;76(7):766–772. [PubMed]
  • Kleinman LC, Kosecoff J, Dubois RW, Brook RH. The medical appropriateness of tympanostomy tubes proposed for children younger than 16 years in the United States. JAMA. 1994 Apr 27;271(16):1250–1255. [PubMed]
  • Phelps CE. The methodologic foundations of studies of the appropriateness of medical care. N Engl J Med. 1993 Oct 21;329(17):1241–1245. [PubMed]
  • Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981 Aug;19(8):855–871. [PubMed]
  • Kreger BE, Restuccia JD. Assessing the need to hospitalize children: pediatric appropriateness evaluation protocol. Pediatrics. 1989 Aug;84(2):242–247. [PubMed]
  • Strumwasser I, Paranjpe NV, Ronis DL, Share D, Sell LJ. Reliability and validity of utilization review criteria. Appropriateness Evaluation Protocol, Standardized Medreview Instrument, and Intensity-Severity-Discharge criteria. Med Care. 1990 Feb;28(2):95–111. [PubMed]
  • Kemper KJ, Fink HD, McCarthy PL. The reliability and validity of the pediatric appropriateness evaluation protocol. QRB Qual Rev Bull. 1989 Mar;15(3):77–80. [PubMed]
  • Dyck FJ, Murphy FA, Murphy JK, Road DA, Boyd MS, Osborne E, De Vlieger D, Korchinski B, Ripley C, Bromley AT, et al. Effect of surveillance on the number of hysterectomies in the province of Saskatchewan. N Engl J Med. 1977 Jun 9;296(23):1326–1328. [PubMed]
  • Roos LL, Bond R, Naylor CD, Chassin MR, Morris AL. Coronary angiography and bypass surgery in Manitoba and the United States: a first comparison. Can J Cardiol. 1994 Jan-Feb;10(1):49–56. [PubMed]
  • McGlynn EA, Naylor CD, Anderson GM, Leape LL, Park RE, Hilborne LH, Bernstein SJ, Goldman BS, Armstrong PW, Keesey JW, et al. Comparison of the appropriateness of coronary angiography and coronary artery bypass graft surgery between Canada and New York State. JAMA. 1994 Sep 28;272(12):934–940. [PubMed]
  • Chassin MR, Kosecoff J, Park RE, Winslow CM, Kahn KL, Merrick NJ, Keesey J, Fink A, Solomon DH, Brook RH. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987 Nov 13;258(18):2533–2537. [PubMed]
  • Chassin MR, Kosecoff J, Solomon DH, Brook RH. How coronary angiography is used. Clinical determinants of appropriateness. JAMA. 1987 Nov 13;258(18):2543–2547. [PubMed]
  • Brook RH, Kosecoff JB, Park RE, Chassin MR, Winslow CM, Hampton JR. Diagnosis and treatment of coronary disease: comparison of doctors' attitudes in the USA and the UK. Lancet. 1988 Apr 2;1(8588):750–753. [PubMed]
  • Bernstein SJ, Hilborne LH, Leape LL, Fiske ME, Park RE, Kamberg CJ, Brook RH. The appropriateness of use of coronary angiography in New York State. JAMA. 1993 Feb 10;269(6):766–769. [PubMed]
  • Winslow CM, Kosecoff JB, Chassin M, Kanouse DE, Brook RH. The appropriateness of performing coronary artery bypass surgery. JAMA. 1988 Jul 22;260(4):505–509. [PubMed]
  • Leape LL, Hilborne LH, Park RE, Bernstein SJ, Kamberg CJ, Sherwood M, Brook RH. The appropriateness of use of coronary artery bypass graft surgery in New York State. JAMA. 1993 Feb 10;269(6):753–760. [PubMed]
  • Merrick NJ, Brook RH, Fink A, Solomon DH. Use of carotid endarterectomy in five California Veterans Administration medical centers. JAMA. 1986 Nov 14;256(18):2531–2535. [PubMed]
  • Winslow CM, Solomon DH, Chassin MR, Kosecoff J, Merrick NJ, Brook RH. The appropriateness of carotid endarterectomy. N Engl J Med. 1988 Mar 24;318(12):721–727. [PubMed]
  • Leape LL, Park RE, Kahan JP, Brook RH. Group judgments of appropriateness: the effect of panel composition. Qual Assur Health Care. 1992 Jun;4(2):151–159. [PubMed]
  • Kahn KL, Kosecoff J, Chassin MR, Solomon DH, Brook RH. The use and misuse of upper gastrointestinal endoscopy. Ann Intern Med. 1988 Oct 15;109(8):664–670. [PubMed]
  • Kahn KL, Kosecoff J, Chassin MR, Flynn MF, Fink A, Pattaphongse N, Solomon DH, Brook RH. Measuring the clinical appropriateness of the use of a procedure. Can we do it? Med Care. 1988 Apr;26(4):415–422. [PubMed]
  • Kahn KL, Park RE, Vennes J, Brook RH. Assigning appropriateness ratings for diagnostic upper gastrointestinal endoscopy using two different approaches. Med Care. 1992 Nov;30(11):1016–1028. [PubMed]
  • Leape LL, Park RE, Solomon DH, Chassin MR, Kosecoff J, Brook RH. Does inappropriate use explain small-area variations in the use of health care services? JAMA. 1990 Feb 2;263(5):669–672. [PubMed]
  • Davidson G. "Does inappropriate use explain small-area variations in the use of health care services?" A critique. Health Serv Res. 1993 Oct;28(4):389–418. [PMC free article] [PubMed]
  • Gloor JE, Kissoon N, Joubert GI. Appropriateness of hospitalization in a Canadian pediatric hospital. Pediatrics. 1993 Jan;91(1):70–74. [PubMed]
  • Smith HE, Sheps S, Matheson DS. Assessing the utilization of in-patient facilities in a Canadian pediatric hospital. Pediatrics. 1993 Oct;92(4):587–593. [PubMed]
  • Kemper KJ. Medically inappropriate hospital use in a pediatric population. N Engl J Med. 1988 Apr 21;318(16):1033–1037. [PubMed]
  • Siu AL, Sonnenberg FA, Manning WG, Goldberg GA, Bloomfield ES, Newhouse JP, Brook RH. Inappropriate use of hospitals in a randomized trial of health insurance plans. N Engl J Med. 1986 Nov 13;315(20):1259–1266. [PubMed]
  • Siu AL, Leibowitz A, Brook RH, Goldman NS, Lurie N, Newhouse JP. Use of the hospital in a randomized trial of prepaid care. JAMA. 1988 Mar 4;259(9):1343–1346. [PubMed]
  • Grumbach K, Bodenheimer T. Reins or fences: a physician's view of cost containment. Health Aff (Millwood) 1990 Winter;9(4):120–126. [PubMed]
  • Anderson G. Implementing practice guidelines. CMAJ. 1993 Mar 1;148(5):753–755. [PMC free article] [PubMed]
  • Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992 Sep 2;268(9):1111–1117. [PubMed]

Articles from CMAJ : Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association