From universalism to selectivity: is 'appropriateness' the answer?

As health expenditures continue to consume increasingly large proportions of national budgets, ways must be found to assure that money spent on health is used for effective services. Only a small proportion of medical decisions are based on scientific evidence about their outcomes, thus it is not surprising that wide variations exist in clinical practice. In recent years, questions have been raised about how medical decisions are made and the proportion of medical procedures and services that are performed for appropriate reasons. One method that has been developed to quantify the amount of inappropriate use is the so-called 'RAND appropriateness method,' which is based on a structured review of the scientific literature and the collective judgement of an expert panel. Measured by this method, a number of procedures have been shown to have high rates of inappropriate or uncertain use. The challenge is to find ways to eliminate ineffective services and procedures to free resources for those that have been proven effective. Further research is needed to improve the method and to find acceptable ways its findings can be used to promote effective care.