Measuring and averting underuse of necessary cardiac procedures: a summary of results and future directions.

BACKGROUND: Attempting to explain the marked variation in utilization of medical procedures has vexed health policy analysts for nearly three decades. Most health services research to date has been directed at identifying and reducing excessive utilization. Little attention has been given to underuse of care. THE LOS ANGELES CARDIAC UNDERUSE PROJECT OVERVIEW: A research group at the University of California, Los Angeles (UCLA), performed two separate, published studies seeking to measure underuse of coronary angiography and coronary artery revascu-larization (bypass surgery and angioplasty), two critical links in the chain of care leading from initial diagnosis of coronary artery disease to definitive treatment. In each study, the necessity criteria developed by the panel were used to identify patients needing an invasive procedure.
RESULTS: Within this population of patients (sampled predominantly from public hospitals), substantial underuse of clinically necessary coronary angiography (41% without refusers) and revascularization (23% without refusers) was detected. In this select population of patients, receiving a necessary revascularization procedure appeared to both reduce the risk of death and improve quality of life. DISCUSSION: Despite limitations of the method, detection of underuse is feasible, valid, and affordable in the context of overall health care expenditures. Moreover, the case for implementing "underuse prevention" systems is increasingly compelling. Measuring and disseminating data on underuse of expensive but highly beneficial procedures would provide health care consumers (patients and employers) with useful information and enable health care providers to develop quality improvement strategies aimed at rational use of health care resources.