Appropriateness in patient care: a new conceptual framework.

In recent years the focus for the evaluation of health services has shifted from unnecessary treatment--specifically, unnecessary surgery--to appropriateness research. This new emphasis constitutes a shift in the burden of proof, indicating increased attention to the evidentiary basis of medical and surgical practice. The evaluation of the appropriateness of health services is also seen as integral to the reforming drive to contain health care costs and improve quality. Because of its pivotal role as a criterion in health care decision-making, the concept of appropriateness requires clarification. Three sources of value are defined that give meaning to "appropriateness" in patient care: the clinical point of view, the point of view of the individual patient, and the societal point of view. The framework is also used to shed light on the issue of medical futility.