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What is appropriate care? An integrative review of emerging themes in the literature

  • Joelle Robertson-Preidler1Email author,
  • Nikola Biller-Andorno1 and
  • Tricia J. Johnson2
BMC Health Services ResearchBMC series – open, inclusive and trusted201717:452

https://doi.org/10.1186/s12913-017-2357-2

Received: 29 July 2015

Accepted: 6 June 2017

Published: 30 June 2017

Abstract

Background

Health care improvement efforts should be aligned in order to make a meaningful impact on health systems. Appropriate care delivery could be a unifying goal to help coordinate efforts to improve health outcomes and ensure system sustainability. A more complete understanding of how appropriate care is currently conceived in research and clinical practice could help inform a more integrated and holistic concept of appropriate care that could guide health care policy and delivery practices. We examined the current understanding of appropriate care by identifying its use and definitions in recently published literature.

Methods

An integrated review of the practices, goals and perspectives of appropriate care in English language peer-reviewed articles published from 2011 to 2016. Inductive content analysis was used to describe emerging themes of appropriate care in articles meeting inclusion criteria.

Results

This integrative review included empirical studies, reviews, and commentaries with various health care settings, cultural contexts, and perspectives. Conceptualizations of appropriate care varied, however most descriptions fell into five main categories: evidence-based care, clinical expertise, patient-centeredness, resource use, and equity. These categories were often used in combination, indicating an integrated understanding of appropriate care.

Conclusions

An understanding of how appropriate care is conceptualized in research and policy can help inform an integrated approach to appropriate care delivery in policy and practice according to the relevant priorities and circumstances.

Keywords

Appropriate care Concept Integrative review

Background

Rising health care costs and strained budgets underscore the need to ensure that scarce health care resources reach the people that most need them. Inappropriate care in the form of under-use, over-use, and misuse of health care services has been recognized by the Institute of Medicine as a barrier to health care quality [1] that plagues health care systems across the world [26] and ultimately reinforces health care disparities that lead to poor health outcomes. To help systems address these challenges, the Institute of Medicine (IOM) created a framework for health systems to bridge gaps in quality and improve outcomes by emphasizing the need for health systems to pursue care that is safe, effective, patient-centered, timely, efficient, and equitable [7]. Furthermore, the Institute for Healthcare Improvement (IHI) developed the Triple Aim of improving population health and patient experience of care while decreasing per capita costs to guide system improvement efforts [8]. Industrialized countries have sought to improve health care delivery through a variety of policies. For example, the Affordable Care Act in the United States seeks to expand access through mandatory health insurance and promote new models of care, such as Accountable Care Organizations, that foster cost-efficient and high quality care [9], though, such efforts are new and the results have been mixed [10]. In other countries, cost-effectiveness criteria for service coverage and pay-for-performance models (e.g. NHS England’s Quality Outcomes Framework for primary care [11]) have attempted to facilitate appropriate care delivery. Understanding how appropriate care delivery is understood and currently used in policy and research could help guide policy makers to take a comprehensive approach to delivering care that aligns with system, clinical, and patient perceptions of appropriate care and improves patient outcomes and experiences while curbing health care spending.

Appropriateness is a recognized element of health care system performance [1214]. The World Health Organization defines appropriateness from a system’s perspective as care that is effective, efficient and in line with ethical principles of fair allocation [15]. Researchers and policy makers have made efforts to conceptualize and measure appropriate care, both prospectively through the development of evidence-based guidelines [1618] and retrospectively by assessing guideline adherence for specific conditions [1820]. A scoping literature review by Sanmartin and colleagues (2008) found that the concept of appropriate care has been chiefly operationalized as the net clinical benefit to the average patient using the RAND/UCLA Appropriateness Method, however, definitions and application of appropriateness varied by setting and service [21].

Although appropriate care has been recognized as an important element of high quality care delivery, the concept remains a patchwork concept with no uniform scope or meaning [21]. In addition, the patient perspective and considerations of patient preferences and values have been largely neglected [21]. A more integrative view of appropriate care delivery could help systems to create effective policies to support clinical practices that can more effectively meet patients’ needs.

The purpose of this paper is to provide a contemporary snapshot of how appropriate care is understood in the post-US health reform world by identifying major themes of appropriate care that can help frame a more comprehensive approach to improving health system performance.

Methods

We conducted an integrative review of recently peer-reviewed literature that focused on appropriate care delivery. Data was coded and analyzed using inductive content analysis to identify major categories to describe how appropriate care is used and conceptualized in research and practice.

Literature search method

We searched Scopus, PubMed, and Medline/Ovid for English-language articles published from 2011 to 2016. Although appropriate care is a dynamic and evolving concept based on government, policy, and market forces [22], the objective of this review was to identify how appropriate care is currently understood and is limited to papers published in the six years following the enactment of the Appropriate Care Act. Search terms included “appropriate care,” “appropriateness of care,” and “care appropriateness.” Because there were no correlating MeSH terms, we searched author keywords which have been found to have correlation with MeSH terms [23] and titles, which have been used as a technique in other reviews to find relevant literature that focus on a specific topic [2426]. We focused our review on adults with decision-making capacity receiving medical care that aims to maintain or restore health by treatment or prevention of disease [27]. We therefore excluded articles that have target populations under the age of 18 and/or focused on non-medical care (e.g., treatment of women in shelters) or dental care. Empirical (qualitative and quantitative) studies, reviews, policy reports, and evidence-based commentaries were included. Non-research based articles and discussions were excluded [28]. Two reviewers separately searched for articles and excluded articles based on eligibility criteria to ensure a systematic and replicable literature retrieval process.

Data analysis

We used inductive content analysis to extract, analyze, and interpret data from the articles that met inclusion criteria. Content analysis is a systematic research method that allows researchers to make valid inferences from data by translating context-specific information into general categories that can be combined into a general statement [29]. This method has three phases: preparation, organizing, and reporting. In the preparation phase, articles were chosen as the unit of analysis and read through to obtain a sense of the data. Article characteristics were extracted, including purpose, methodology, country, healthcare setting, care description, and target population. Next, data on how articles conceptualized appropriate care was organized through coding, category creation and abstraction. After thorough examination of article content, articles’ conceptualization of appropriate care was recorded through a summary definition. From this content, themes and subthemes were further abstracted into main categories. Major themes were inductively constructed from the emerging categories. Abstraction was performed by JR-P and repeated by TJ for a subsample to validate method reliability.

Results

Literature retrieval

The literature search yielded 306 articles published between since 2011 and 2016 (Fig. 1). After filtering for duplicate records, 122 articles were considered for review. Sixty-three of these articles were subsequently excluded because they did not meet eligibility criteria. Fifty-nine articles were eligible for abstraction [5, 3087].
Fig. 1

Flow diagram of literature selection

Study description

The reviewed literature included quantitative studies (N = 21), qualitative studies (N = 6), mixed methods designs (N = 7), case studies (N = 2), reviews and policy papers (N = 14), and commentaries (N = 9) (Table 1). Thirty of the articles were either conducted in the US (for empirical studies) or written from the US perspective, and 18 were conducted in or based on a perspective from other industrialized countries, including Canada (N = 6), Australia (N = 6), Italy (N = 5), England or the UK (N = 5), Japan (N = 2), Israel (N = 2), the Netherlands (N = 1), Switzerland (N = 2), Germany (N = 1), Ireland (N = 1) and the European region (N = 2) (Table 1). Five articles spanned more than one country or had an international focus and only one study took place in a developing nation, (i.e., Afghanistan).
Table 1

Description of articles

Author, year

Type of article

Purpose

Country

Setting

Perspective

Type of care

Target population

Ackermann, 2012 [46]

Commentary

To challenge the use of mere clinical practice guidelines to inform quality measurement and performance assessment in primary care

Australia

Primary

System, clinical

Not specified

GP patients

Anstey et al., 2015 [51]

Cross-sectional study using surveys

To determine the extent and characteristics of perceived inappropriate treatment among ICU doctors and nurses

USA

Inpatient

Clinical

ICU care

ICU patients

Barber et al., 2015 [52]

Mixed method, qualitative, review

To develop key performance indicators to evaluate centralized intake systems for patients with osteoarthritis and rheumatoid arthritis

Canada

Various

System

Various

Patients with osteoarthritis and rheumatoid arthritis

Bateson, 2013 [39]

Review

To evaluate the potential role of GPs to reduce unnecessary female genital surgery, while also providing culturally sensitive care

Australia

Primary

Clinical

Procedure counseling and referral

Women who have had or are requesting genital cutting

Bonvicini et al., 2014 [30]

Observational, population-based study

To compare Caesarian section (CS) and ultrasound scan utilization in a public vs. private model of care and the association of use with perinatal outcomes

Italy

Specialized, inpatient, integrated

Clinical

Use of ultrasound and frequency of CS during prenatal care and delivery

Women giving birth in Reggio Emilia Province

Bradford et al., 2015 [53]

Qualitative methods and consensus process

To customize the existing IT-enabled cardiac rehabilitation program delivered by mobile phone through a smartphone app to make it culturally relevant and suitable for Indigenous Australians living in urban and remote communities

Australia

Rehabilitation, Remote care

Patient

Remote cardiac rehabilitation

Indigenous Australians

Breivik et al., 2013 [40]

Review

To make a case for prioritizing chronic pain management in Europe, outline strategies to overcome barriers to effective pain care, and address the confusion of proper uses of opioid medications

Europe

Primary, specialized, inpatient, integrated, other

System

Chronic pain management therapies

European adults with chronic pain

Brien et al., 2014 [41]

Review

To conduct a scoping review to map Canadian research and related activity on system-level appropriateness of care

Canada

Not specified

System

Not specified

Patients in Quebec

Brindis et al., 2011 [42]

Review

To evaluate how Maryland hospitals dealt with issues of inappropriate use of cardiac procedures through new policy initiatives

USA

Inpatient

System

Percutaneous coronary intervention (PCI) and stenting

Patients that have received or may prospectively need PCI

Broekhuis et al., 2014 [54]

Cross-sectional study using surveys

To study the appropriateness of walk-in clinic visits in Quebec, Canada

Canada

Walk-in clinics

Clinical; patient

General

Not specified

Brooks et al., 2013 [73]

Qualitative, mixed methods

To provide a model for adapting remote monitoring to specific populations who are undergoing care for post-traumatic stress disorder (PTSD)

USA

Telehealth

Clinical; patient

Telehealth monitoring for PTSD

American Indian Veterans with PTSD

Chen, 2011 [43]

Review

To evaluate the medical, functional, and quality of life costs of Parkinson's Disease and to discuss treatments that help manage better outcomes

USA

Primary, specialized, integrated, other

System; clinical

Parkinson's disease management therapies

Adults with Parkinson's disease

D’Alleyrand & O’Toole, 2013 [44]

Review

To evaluate the treatment trends in the literature on appropriate timing of (femoral) fractures in polytrauma patients following an injury and discuss the new concept of Early Appropriate Care

USA

Inpatient

Clinical

Fixation surgery for femoral fractures

Polytrauma patients with femoral fractures

Fanari et al., 2015 [76]

Case studies

To highlight how quality measures that aim to decrease Door-to-Balloon-Time (the time from suspected myocardial infarction presentation to primary coronary intervention) may result in poor outcomes due to rushed triage decisions

USA

Inpatient

Clinical

Procedures in the coronary catheterization lab

Patients with suspected myocardial infarction

Fuchs, 2011 [47]

Commentary

To discuss how doctors can be incentivized to provide appropriate care utilization given the dilemma of fulfilling the commitment to the primacy of patient welfare and providing cost-effective care

USA

Not specified

System; clinical

Not specified

Not specified

Hosaka et al., 2011 [31]

Retrospective data analysis

To evaluate the association between the number of blood cultures collected and the appropriateness of care for suspected bacteremic community-acquired urinary tract infection (UTI) in the elderly

Japan

Inpatient

Clinical

Blood cultures collection and UTI treatment

Elderly patients with suspected UTI

Hubbard & Jatoi, 2012

Commentary

To discuss why adjunctive chemotherapy is less used in the elderly than in younger populations

USA

Specialized

Clinical

Adjunctive chemotherapy for colon cancer

Older (vs. younger) colon cancer patients

Kazandijian & Lipitz-Snyderman, 2011 [55]

Review

To discuss the usefulness of health care information technology in assisting care providers to minimize uncertainty while simultaneously increasing efficiency of the care provided

USA

Inpatient

System; clinical

Not specified/ general

Inpatient

King et al., 2013 [32]

Pre-post test

To institute and assess the impact of a process improvement project for blood utilization to ensure appropriateness in transfusion practice

USA

Inpatient

Clinical

Blood transfusions and red blood cell unit usage

Anemic patients, patients that may need transfusions

Korst et al., 2015 [56]

Cross-sectional survey

To examine the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care

USA

Inpatient

Clinical

Perinatal care

Women giving birth in California hospitals

Korst et al., 2015 [57]

Conceptual framework and quantitative survey

To describe the resources and activities associated with childbirth services

USA

Inpatient

Clinical

Perinatal care

Women giving birth in California hospitals

Liang et al., 2012 [33]

Longitudinal study

To examine the racial/ ethnic differences in prostate-specific antigen (PSA) testing and follow-up in primary care practices serving an indigent population

USA

Primary

System; clinical

PSA testing and follow-up

Indigent men in South Texas

Lin & Harris, 2015 [58]

Commentary

To address the issues of variation in interpretation when applying appropriate use criteria in cardiology diagnostic imaging

USA

Not specified

System; clinical

Cardiology diagnostic imaging

Cardiology patients

Lippi & Favaloro, 2011 [49]

Commentary

To identify problems associated with diagnosing bleeding disorders and suggest possible solutions

Italy, Australia

Primary, specialized, integrated, other

Clinical

Diagnosis of bleeding disorders

Patients with hemophilia

Martin, 2012 [59]

Qualitative study using in-depth interviews

To explore older Iranian immigrants' perceptions/ experiences of discrimination in their encounter with the American health care system

USA

Not specified

Patient

Not specified/ general

Iranian immigrant patients that immigrated after age 50, All had health insurance

Mancuso et al., 2016 [71]

Quantitative

To investigate the relationship between care appropriateness and productivity evolution in public hospital services in 20 Italian region systems for the period 2008-2012

Italy

Inpatient

System

Not specified

Not specified

Mataoui & Sheldon, 2016 [60]

Commentary

To call attention to the importance of oncology nurses to develop a deeper understanding of the cultural practices and health beliefs of Muslim patients when providing cancer care

USA

Not specified

Patient

Oncology/ cancer care

Muslim cancer patients

Matthie, 2015 [78]

Literature review and case studies

To highlight prominent issues of pain treatment for sickle cell disease (SCD) and make recommendations to hospital nursing staff on how to improve care for adults with SCD

USA

Inpatient

Clinical; patient

Sickle cell disease pain treatment

Patients with presenting with sickle cell disease related pain episodes

McCormick, 2014 [61]

Commentary

To call attention to the importance of culturally sensitive care and identify tips for cultural sensitivity

USA

Not specified

Patient

Not specified/ general

Culturally diverse, older patients

McFadden et al. 2013 [62]

Qualitative study using interviews

To explore the extent to which cultural context makes a difference to experiences of breast-feeding support for women of Bangladeshi origin and to consider the implications for the provision of culturally appropriate care

England

Inpatient, community/ home-based care

Patient

Maternity care and breast feeding support

Breast feeding women of Bangladeshi origin

Mitchell et al., 2016 [79]

Quantitative

To evaluate the diagnostic outcomes and therapeutic decisions made after a repeat pancreatic cancer testing using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for patients that have undergone a prior testing with inconclusive results

Canada

Inpatient

Clinical

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA)

Patients undergoing EUS-FNA after initial testing for pancreatic cancer was inconclusive

Mochizuki, 2012 [63]

Review

To describe current cultural issues in Japanese health care services that have resulted from increased immigration

Japan

Not specified

System; patient

Not specified

Foreigners, ethnically, culturally diverse patients

Morgan et al., 2015 [64]

Retrospective database cross-sectional analysis

To establish the prevalence and nature of pathology test-ordering of GP trainees, and to describe the associations of this test-ordering (in the context of increasing over-testing and implications for patient safety)

Australia

Primary (urban and rural settings)

Clinical

Not specified/ general

Not specified

Nahm et al., 2011 [34]

Retrospective database cross-sectional analysis

To examine the effects of timing of fixation and investigate risk factors for complications

USA

Inpatient

Clinical

Femur fracture stabilization in patients with multiple injuries

Patients with femoral fractures

Newbrander et al., 2014 [65]

Qualitative study

To explore traditional practices of women, families, and communities related to maternal and newborn care, and sociocultural and health system issues that create access barriers

Afghanistan

Home versus health care facilities

System; patient

Perinatal, antenatal, and newborn care

Women giving birth or have recently given birth, newborns

Panella et al., 2012 [35]

Multi-center cluster-randomized trial

To evaluate whether Clinical Pathways improve the outcomes and the quality of care provided to patients after acute ischemic stroke

Italy

Inpatient

Clinical

Post-acute ischemic stroke care

Patients that have just had an acute ischemic stroke

Pape et al., 2016 [80]

Commentary

To critique the parameters of the Early Appropriate Care protocol for determining whether patients are cleared for stabilization surgery

Germany

Inpatient

Clinical

Surgical stabilization of fractures

Trauma patients with fractures

Paprica et al., 2015 [66]

Literature review, consensus process

To explore whether the direct involvement of policy stakeholders could advance appropriateness and disinvestment

Canada

Not specified

System

Not specified

Patients in Canada

Piers et al., 2011 [5]

Cross-sectional survey

To determine the prevalence of perceived inappropriateness of care among intensive care unit (ICU) clinicians

Europe, Israel

Inpatient

Clinical

ICU services

ICU patients

Pittet et al., 2015 [87]

Quantitative questionnaire of a simulated case and qualitative methods using focus groups

To explore how treatment decisions of practicing gastroenterologists differ from those of experts, using a vignette case study and a focus group

Switzerland

Specialized

Clinical

Gastroenterology; treatment of Crohn's disease and ulcerative colitis

Hypothetical Crohn's disease and ulcerative colitis patients

Poulos et al., 2011 [36]

Cohort study

To report utilization review data on inpatients in acute care with stroke, hip fracture or elective joint replacement, and other inpatients referred for rehabilitation

Australia

Inpatient, integrated, other

Clinical

Readiness of transfer to rehabilitation

Inpatients in acute care with stroke, hip fracture or elective joint replacement

Reich et al., 2016 [81]

Cohort study

To evaluate whether Early Appropriate Care protocol for stabilizing fractures in patients with advanced age require unique parameters to mitigate complications

USA

Inpatient

Clinical

Surgical stabilization of fractures

Skeletally mature trauma patients with unstable fractures

Russo et al., 2016

Quantitative survey

To investigate the interplay between perceptions of individual employees regarding HR practices and the variability of such perceptions within the department and their effects on appropriateness of care

Italy

Inpatient

Clinical

Not specified

Not specified

Sandela et al., 2012

Cross-sectional analysis of simulated case

To investigate the appropriateness and cost of care and quantify their relationship to performance based on a simulated case

USA

Primary

Clinical

Simulated case of a 45-year-old man complaining of right-sided localized chest pain

Simulated case

Schneider, 2014 [83]

Case studies

To illustrate the importance of early digestive tract assessment impact on the outcomes of liver transplantation after acetaminophen poisoning

UK

Inpatient

Clinical

Emergency liver transplantation after acetaminophen poisoning

Patients needing liver transplants who suffer acetaminophen poisoning

Schoormans et al., 2013 [50]

Commentary

To discuss care provision problems of congenital heart disease (CHD) patients lost to follow-up, those receiving too little care, and those receiving too much care, and offers appropriate and cost-effective health care delivery targets

Netherlands

Primary, specialized, inpatient, integrated, other

System; patient

CHD long-term treatment and management

Adults with CHD

Sharpe & Uchendu, 2014 [45]

Review

To address the issues of discrimination and inadequate health care provision for LGBT veterans through new policies that align with the Veteran’s Health Administration's Strategic Plan 2013-2018

USA

Not specified

System; patient

Not specified

LGBT Veterans

Tasker et al., 2014 [67]

Review

To review evidence of performing damage control orthopedics versus definitive stabilization and the use of Early Appropriate Care protocols

UK

Inpatient

Clinical

Stabilization of fractures

Polytrauma patients with fractures

Tolson et al., 2011 [68]

Policy paper

To report the outcomes of a workshop by the International Association of Gerontology and Geriatrics about recommendations for improving quality of care experiences for older people in nursing homes around the world

International

Nursing homes

System; patient

Geriatric care, pain management, end of life care

Residents of nursing homes

Trinh et al., 2014 [74]

Quantitative survey and qualitative interviews

To describe the challenges implementing the Culturally Focused Psychiatric Consultation Program for depressed Latino and Asian Americans in four urban primary care practices

USA

Primary

Patient

Psychiatric consultation for depression

Latino and Asian Americans

Trinh et al., 2015 [75]

Qualitative interviews

To evaluate participant acceptability of a Culturally Focused Psychiatric Consultation Program for depressed Latino Americans

USA

Primary

Clinical; patient

Psychiatric consultation for depression

Latino Americans

Tucker et al., 2013 [69]

Review

To report the literature review findings of examples of the balance of care approach framework during a 40-year time span

Mostly UK, Ireland, Canada

Various

System

Various

Various (health, social, and mental care)

Vallier et al., 2013 [38]

Statistical modeling based on retrospective database cross-sectional analysis

To define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures and develop a model to predict complications

USA

Inpatient

Clinical

Definitive fixation for pelvis, femur, acetabulum, and spine fractures

Adults with pelvis, acetabulum, spine, and/or proximal or diaphyseal femur fractures

Vallier et al., 2015 [70]

Prospective study

To review initial experiences with a protocol (to determine the timing of definitive fracture care based on the adequacy of resuscitation) with adherence to the protocol and assess barriers to implementation

USA

Inpatient

Clinical

Definitive fixation of pelvis, acetabulum, spine and femur fractures within 36 hours of injury

Polytrauma, adult patients with fractures

Vallier et al., 2016 [84]

Prospective study

To evaluate whether a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay

USA

Inpatient

Clinical

Surgical stabilization of fractures

Trauma patients with femur, pelvis or spine fractures

Vaucher et al., 2016 [71]

Qualitative study using focus groups

To explore and compare gastroenterologists’ and patients' perceptions of risks and benefits of treatments and prioritizations of expected outcomes

Switzerland

Specialized

Clinical; patient

Treatment of inflammatory bowel disease including ulcerative colitis and Crohn's disease

Patients with ulcerative colitis and Crohn's disease

Weideman et al., 2015

Mixed methods

To design, implement, and evaluate a virtual simulation experience facilitating student access to diverse cultures and strengthening their ability to provide culturally congruent care.

USA

Specialized; Virtual simulation of pre- and post-natal care

Clinical; patient

Pre- and post-natal care

Simulated Amish and African American patients

Weinberg et al., 2015 [72]

Case control study

To better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using the Early Appropriate Care protocol

USA

Inpatient

Clinical

Treatment of orthopedic fractures

Trauma patients with orthopedic fractures

Wynell-Mayow, et al., 2016 [85]

Pre-post test

To assess the impact of the Cambridge Polytrauma Pathway on quality process indicators

UK

Inpatient

Clinical

Treatment of orthopedic polytrauma

Trauma patients with orthopedic fractures

Article characteristics

Table 1 provides a description of the articles included in the review. Of the articles that specified health care setting, most took place in the hospital (N = 30). Other settings included primary care (N = 11), secondary or specialized care (N = 8), integrated care or care that took place in more than one setting (N = 8), other types of care settings such as home health, nursing homes, urgent care walk-in clinics, and remote care (i.e. telehealth) (N = 13), and settings that were not specified (N = 12). Articles focused on therapeutic procedures (e.g., stenting, fracture stabilization surgery), diagnostic testing (e.g., PSA testing for prostate cancer, blood culture collection for UTI diagnosis), condition management or monitoring (e.g., chronic pain management, telehealth monitoring for PTSD), setting - specific care (e.g., intensive care unit services and primary care services), and age-specific care (e.g., geriatric care). Most articles related to specific health conditions (N = 38), including orthopedic fractures (N = 11), obstetrics and maternity care (N = 6), cardiac and cardiovascular conditions (N = 7), cancer (N = 4), mental health (N = 3), pain management (N = 2), bleeding disorders (N = 2), gastrointestinal disorders (N = 2), and other medical conditions (i.e., sickle cell disease, Parkinson’s disease, arthritis, liver failure, and urinary tract infection). Eleven of the 59 articles focused on minority patients or populations, six articles targeted older patients, four articles focused on women and one focused on men. Most articles defined appropriate care from a clinical perspective (N = 39), more than a third of studies defined appropriate care from the health system perspective (N = 22), and slightly less than a third were defined from the patient perspective (N = 16). Sixteen articles represented more than one perspective.

Main results

During the review process, five categories emerged from the inductive content analysis of the articles’ full text. These categories included evidence-based care, patient-centeredness, clinical expertise, effective use of resources, and equity (Fig. 2).
Fig. 2

Categories of appropriate care

Evidence-based care

Forty articles discussed elements of evidence-based care, which we define as care that is proven to improve health outcomes. Evidence-based care included outcomes research, the assessment and use of evidence-based standards (i.e., guidelines, quality indicators), and the use of scientific evidence in treatment (Fig. 3). Appropriate care was determined based on positive health outcomes, adherence to evidence-based guidelines, and applying evidence in practice. One prominent theme in the outcomes-based literature was creating and testing Early Appropriate Care, an evidence-based protocol for timing stabilization of fractures after traumatic injury. Other studies focused on evaluating clinical effectiveness and guideline adherence from a systems-level perspective to reduce unnecessary care [33, 55, 69, 79] and decrease outcome variation [35, 36, 40, 49, 53, 55, 86] and from a clinical perspective to ensure safe and effective care [3436, 41, 42, 46, 49, 67, 68, 70, 80, 81, 85]. In addition, many articles indicated the need for more evidence and guidelines to guide clinical decisions, especially for populations that are underrepresented in research, such LGBT patients [45] and the elderly [48, 68].
Fig. 3

Evidence-based care

Some commentaries and case studies questioned the ability of evidence and guidelines to account for context or real world disease complexity. For example, commentaries by Lin (2015) and Lippi & Favaloro (2012) discuss guideline interpretation and implementation challenges that can lead to negative outcomes [49, 58] and case studies by Schneider (2014) and Fanari (2015) illustrate how gaps in guidelines can cause clinicians to overlook vital elements of appropriate care, which can lead to poor outcomes if practices are not effectively monitored [76, 83]. Ackerman (2012) also challenged the use of guidelines, stating that guidelines must be combined with clinical expertise and patient values to ensure appropriate care delivery [46].

Clinical expertise

Thirty-eight articles discussed the importance of clinical expertise in appropriate care delivery. Articles defined appropriate care in terms of adequate education and training for health care professionals, the use of expert opinion/ professional consensus to guide clinical decisions, and clinician discretion to tailor treatment to patient cases and to manage uncertainty (Fig. 4). Articles emphasized the importance of education and training in specialty medical fields [68], the proper use of guidelines and protocols [32], and cultural competence and effective communication to help clinicians identify patient-specific risks and needs, align treatment goals, and enable shared decision-making [39, 45, 55, 5963, 68, 71, 74, 75, 78, 86]. To ensure effective communication within the therapeutic relationship, articles also discussed the need to overcome language barriers [62, 63, 74, 75].
Fig. 4

Clinical expertise

Professional discretion was viewed as an important element of appropriate care that enables clinicians to assess necessity [5, 36, 47, 51, 54, 66], translate evidence for specific patient risks, needs, and goals [36, 43, 45, 46, 55, 66, 68, 71, 87], balance patient needs with costs [47], and manage uncertainty [30, 43, 47, 55, 64, 66].

Professional consensus and knowledge exchange appeared throughout the literature as tools for making appropriate care decisions to reduce variation in service use [41, 42, 58, 66], confirm indications [37, 64], coordinate care [73], manage uncertainty [43, 55, 64], and create standards and guidelines [33, 34, 36, 46, 53, 84].

Patient-centeredness

Considerations of patient-centered care were present in about half of the reviewed articles (N = 30). Elements of patient-centeredness included providing patients with context-specific, responsive, coordinated care and supporting patient autonomy through open communication and shared decision-making (Fig. 5). Context-specific care tailors health care services to patients’ health profile, medical history, and risk factors [33, 36, 43, 45, 49, 55, 61, 62, 64, 68, 87]. Responsiveness refers to culturally sensitive and respectful care that accounts for patient values, culture, needs and preferences. Responsiveness was especially emphasized in articles that focused on providing culturally appropriate care to various groups, including immigrant minorities [59, 6163], LGBT veterans [45], and women in Afghanistan [65]. Coordinated and integrated care involves managing health and social services across conditions and settings [36, 39, 40, 43, 50, 68, 73] (Fig. 5). Other elements of patient-centered care included shared decision-making through open communication of goals and expectations [49, 55, 60, 68, 71] that help identify patient perceptions and acceptability of care [40, 43, 50, 53, 54, 60, 61, 68, 71], health literacy and patient activation [33, 52, 65], and building a relationship of trust with providers [45, 60, 61, 65]. Patient-centered care requires patient empowerment and engagement through disease prevention and self-management tools, education, and effective communication.
Fig. 5

Patient-centeredness

Resource use

The role of resource use in determining appropriate care was discussed in 33 articles. Subthemes included variation in resource use, cost-effectiveness, and health care setting (Fig. 6). Twenty articles discussed variation in resource use to reduce waste and unnecessary care and ensure proper provision [33, 40, 42, 47, 50, 5658, 64, 66, 82] and to assess equity in health care delivery practices [33, 45, 50, 58, 63]. Cost-effectiveness was discussed in terms of allocating resources at the health system level [41, 66, 69, 77], making clinical decisions in practice [37, 43, 47, 58, 82], and decreasing cost in damage care orthopedics [67].
Fig. 6

Resource use

Equity

Equity was discussed in 14 articles. This category included many themes that overlap previously discussed themes, including demographic and geographic variation in resource use [33, 40, 42, 50, 58, 63] and health related outcomes [33, 45, 50, 57, 60, 63], access to health care services [33, 45, 52, 60, 63, 65, 68, 75, 74, 78, 79], and non-discriminatory care [45, 59, 62, 78] (Fig. 7).
Fig. 7

Equity

Discussion

Using content analysis, this integrative review identified emerging themes from the literature to inform a more integrated approach to appropriate care. Although the use of appropriate care in the literature varied, our review revealed five emerging categories: evidence-based care, clinical expertise, patient-centeredness, resource use, and equity, which were employed in varying combination with overlapping themes and subthemes (Figs. 3, 4, 5, 6 and 7). These elements correspond with the IOM’s performance targets of proving safe, effective, patient-centered, timely, efficient, equitable care and provides guidance for how systems can achieve the IHI’s Triple Aim of improving population health, improving experiences of care, and decreasing per capita costs [7, 8].

Most articles conceptualized appropriate care from a clinical perspective using outcomes research, peer consensus, and guideline adherence to determine whether care was appropriate. The system perspective defined appropriate care in terms of guideline adherence, cost-effectiveness, and reduced variation in resource use and outcomes between geographic regions, health care facilities, and demographic groups. These findings contrast with findings from the review by Sanmartin et al. (2008) that found appropriateness of care to be most often defined according to RAND/UCLA Appropriateness Methods [21], and better correspond with Brien et al.’s (2014) review of system level appropriateness in Canada, which found appropriate care to be defined in terms of health services utilization, accordance with guidelines, and cost-effectiveness [41]. However, unlike past reviews, this review found more representation of the patient perspective that focused on tailoring evidence-based care to account for patient needs and preferences and providing culturally sensitive care.

Emphasis on research outcomes and evidence-based guidelines conveyed a reliance on evidence-based measures to mitigate uncertainty in clinical decision-making and reduce variations in health care delivery practices. Researchers with the Dartmouth Atlas Project that investigates variation in care refer to clear-cut evidence - based treatment as effective care and assert that it should always be used in indicated circumstances [88]. However, the review also questioned the sole reliance on evidence to determine appropriateness as insufficient and sometimes even dangerous. Limited evidence for certain populations and conditions, as well as disease - specific guidelines were shown to not always account for disease complexity and patient variability and leave a degree of ambiguity and uncertainty that must be qualified by clinician discretion, patient input, and effective monitoring. Research by other authors also discusses the limits of evidence for providing patient-centered care. Reeve and colleagues (2013) found that English primary care physicians are skeptical of “tick-box” models of care that evaluate performance based on disease-specific guidelines, because they are often unable to account for the high degree of complexity and uncertainty that is common in primary care [89]. Reeve (2010) therefore espouses the use of Interpretive Medicine that allows physicians to use a range of evidence and context-specific knowledge to interpret patients’ experience of illness [90].

Furthermore, findings from our review suggest that patient input and expertise may be able to guide appropriate care decisions. Articles in the review discussed the role of patients in determining appropriate care when different options with varying long and short-term effects exist, such as therapies for Parkinson’s Disease [43], chronic gastrointestinal conditions [71], or end of life care [68]. Anstey et al. (2016) and Piers et al. (2011) found that effective communication with patients’ families about end of life care could also decrease overuse of unnecessary or futile care in the intensive care unit [51, 5]. In the US context, the Dartmouth Atlas developed the term preference sensitive care to describe care with many viable options and tradeoffs that can only be deemed appropriate by the patient [91]. Preference sensitive care not only ensures that care is appropriate for patient - specific needs and goals, but also helps to curb unnecessary variation in services due to resource availability and perverse incentives for providing care. Empowering patients to take an active role in health care seeking and decisions can also contribute to appropriate care delivery by providing patients with education and tools to overcome barriers to access (e.g., Afghani women requiring perinatal services [65]); manage chronic conditions (e.g. people with arthritis waiting to receive services [52]) ; understand risks of elective procedures (e.g. women seeking genital surgery [39]); and communicate their health needs and risk factors without fear of discrimination (e.g., LGBT veterans [45]). Furthermore, the Choosing Wisely campaign has tried to harness patient expertise to mitigate overuse by providing patients with a list of relevant questions to ask their doctors when they are making specific health care decisions [17].

Although evidence-based care, professional expertise, patient-centeredness, resource use, and equity were discussed across health care contexts, conceptualizations of how these elements should be applied varied by health care system especially in terms of appropriate allocation of resources, reinforcing Sharpe’s (1997) claim that system level appropriateness is shaped by system values and priorities for resource allocation and equity [22]. Appropriate care in health systems with tax-based financing (e.g. Italy, Australia, Canada, England) emphasized monitoring cost-effectiveness, while appropriate care in more market-based health systems (e.g. USA, the Netherlands) focused on reducing resource and outcome variation. Furthermore, the use of provider incentives was discussed in the light of the relative country context. Fuchs (2011) advocated for the use of capitation in the US to curb costs and replace traditional fee-for-service models [47]. However, because managed care has come under scrutiny in the US for cutting costs at the expense of quality, the Affordable Care Act has launched new models of delivery that tie quality to remuneration and provide opportunities for providers to share savings [90]. Conversely, Ackermann (2012) discussed how performance-based incentives in the Australian context could facilitate unintended “perverse” incentives to over-treat or undertreat, giving the example of how the Medicare Benefits Schedule remunerates practitioners for Type 2 Diabetes screening if the screen is positive, creating an incentive not to screen and to overdiagnose [46]. Pape et al. (2016) illustrated how even clear-cut evidence-based guidelines, such as Early Appropriate Care for determining the timing of fracture surgery, can be context - specific due to the use of different emergency room procedures in different countries [80]. Furthermore, countries with large minority communities (i.e., USA, Australia, England) or rising rates of immigration (i.e., USA, Japan) emphasized the importance of cultural competence and respect for delivering appropriate care to diverse patients [53, 5963, 73, 45].

Although understandings of appropriateness inevitably vary by context, the review gleaned implications for appropriate care provision. The importance of evidence-based care and guidelines to support clinical decision-making points to a need for further investment in research and infrastructure that make evidence accessible to health care practitioners. Guideline and protocol development should also include clinician input on implementation challenges, education and training, and feedback mechanisms [32] to prevent against misuse and misinterpretation that can lead to inappropriate diagnosis and care [58]. In addition, increased awareness of patient diversity and unique needs require medical schools and continuing education programs to include cultural competency and communication training to facilitate person-based care and shared decision-making.

This review considers the insights from varying perspectives of appropriate care to create a more comprehensive view of appropriate care delivery that includes every level of the health care system. However, this review is limited by its focus on adult populations, English language literature, specific search terms, and publication years. Future research could employ more scoping review methods to evaluate the use and understanding of appropriate care and how it changes according to population and context.

Conclusion

Although conceptualizations of appropriate care vary in the literature, they are often characterized by evidence-based care, clinical expertise, patient-centeredness, resource use, and equity. Evidence-based care is essential to providing appropriate care, but must be qualified by clinician discretion, respect for patient wishes and values, and context - specific concepts of equitable distribution of resources. This integrated understanding of appropriate care can help inform policy and clinical delivery practices according to context-specific means and priorities.

Abbreviations

CHD: 

Congenital heart disease

CP: 

Clinical pathways

CS: 

Caesarian section

GP: 

General practitioner

ICU: 

Intensive care unit

LGBT: 

Lesbian, gay, bisexual, and transgender

LOS: 

Length of stay

PCI: 

Percutaneous coronary intervention

PSA: 

Prostate-specific antigen

QOL: 

Quality of life

UTI: 

Urinary tract infection

VHA: 

Veterans health administration

Declarations

Acknowledgements

Not applicable.

Funding

There was no funding for the research or the writing of this paper.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Authors’ contributions

All authors were involved in the conceptualization and design of the review. JR-P and TJ collected the literature and selected articles for review based on eligibility criteria agreed upon by all authors. JR-P and TJ reviewed articles and JR-P, NB-A, and TJ were involved in the analysis and interpretation of the data. JR-P drafted the article and NB-A and TJ critically revised the manuscript for important intellectual content. All authors approved final version for submission.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Publisher’s Note

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Authors’ Affiliations

(1)
Institute of Biomedical Ethics and History of Medicine, University of Zurich
(2)
Department of Health Systems Management, Rush University

References

  1. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on health care quality. JAMA. 1998;280(11):1000–5.View ArticlePubMedGoogle Scholar
  2. Asch SM, Sloss EM, Hogan C, Brook RH, Kravitz RL. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA. 2000;284(18):2325–33.View ArticlePubMedGoogle Scholar
  3. Liu X, Mills A. Evaluating payment mechanisms: how can we measure unnecessary care? Health Policy Plan. 1999;14(4):409–13.View ArticlePubMedGoogle Scholar
  4. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.Google Scholar
  5. Piers RD, Azoulay E, Ricou B, Dekeyser Ganz F, Decruyenaere J, Max A, Michalsen A, Maia PA, Owczuk R, Rubulotta F, Depuydt P, Meert AP, Reyners AK, Aquilina A, Bekaert M, Van den Noortgate NJ, Schrauwen WJ, Benoit DD, APPROPRICUS Study Group of the Ethics Section of the ESICM. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA 2011;306(24):2694–2703.Google Scholar
  6. Schoen C, Osborn R, How SK, Doty MM, Peugh J. In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008. Health Aff (Millwood). 2009;28(1):w1–16.View ArticlePubMedGoogle Scholar
  7. Institute of Medicine (US) Committee on Crossing the Quality Chasm. A framework for improving quality. In: Anonymous improving the quality of health care for mental and substance-use conditions: quality Chasm series. Washington DC: National Academies Press; 2006.Google Scholar
  8. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–69.View ArticleGoogle Scholar
  9. Anonymous Accountable care organizations. In: Centers for Medicare and Medicaid Services (CMS). 2013. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/. Accessed 9 Jan 2014.
  10. James J. Health policy brief: pay-for-performance. In: Health Affairs. 2012. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=78. Accessed 15 Nov 2014.
  11. Anonymous Quality and Outcomes Framework. In: Health and Social Care Information Centre (HSCIC). 2015. http://www.hscic.gov.uk/qof. Accessed 8 Apr 2016.
  12. Arah OA, Westert GP, Hurst J, Klazinga NS. A conceptual framework for the OECD health care quality indicators project. Int J Qual Health Care. 2006;18(Suppl 1):5–13.View ArticlePubMedGoogle Scholar
  13. Canadian Institute for Health Information (CIHI). A performance measurement framework for the Canadian health system. 2013.Google Scholar
  14. The Commonwealth Fund. First report and recommendations of the Commonwealth Fund’s international working group on quality indicators. 2004.Google Scholar
  15. Anonymous Proceedings of the Appropriateness in Health Care Services. 23–25 March 2000; Koblenz, Germany. Copenhagen: World Health Organization; 2000.Google Scholar
  16. Centers for Medicare and Medicaid Services (CMS), HHS. Medicare program; changes to the hospital inpatient prospective payment system for acute care hospitals and fiscal year 2010 rates; and changes to the long-term care hospital prospective payment system and rate years 2010 and 2009 rates. Final rules and interim final rule with comment period. Fed Regist. 2009;74(165):43753–4236.Google Scholar
  17. Anonymous Choosing Wisely. 2016. http://www.choosingwisely.org/. Accessed 9 Jan 2016.
  18. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, van het Loo M, McDonnell J, Vader JP, Kahan JP. The RAND/UCLA appropriateness method user’s manual. 2001.Google Scholar
  19. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100–5.Google Scholar
  20. Medicare.gov. Hospital compare: timely and effective care. 2014. http://medicare.gov/hospitalcompare/About/Timely-Effective-Care.html. Accessed 1 Jan 2015.
  21. Sanmartin C, Murphy K, Choptain N, Conner-Spady B, McLaren L, Bohm E, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3):342–9.Google Scholar
  22. Sharpe VA. The politics, economics, and ethics of “appropriateness”. Kennedy Inst Ethics J. 1997;7(4):337–43.View ArticlePubMedGoogle Scholar
  23. Névéol A, Doğan RI, Lu Z. Author keywords in Biomedical journal articles. AMIA Ann Symp Proc. 2010;2010:537–41.Google Scholar
  24. van Wyk K, Backwell A, Townson A. A narrative literature review to direct spinal cord injury patient education programming. Top Spinal Cord Inj Rehabil. 2015;21(1):49–60.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Yoon PD, Chalasani V, Woo HH. Systematic review and meta-analysis on management of acute urinary retention. Prostate Cancer Prostatic Dis. 2015;18(4):297–302.View ArticlePubMedGoogle Scholar
  26. Caldeira S, Timmins F. Resilience: synthesis of concept analyses and contribution to nursing classifications. Int Nurs Rev. 2016;63(2):191–9.View ArticlePubMedGoogle Scholar
  27. Anonymous Medical definition of health care. In: Merriam-Webster Medical Dictionary. 2016. http://www.merriam-webster.com/medical/health%20care. Accessed 15 Apr 2016.
  28. Chiu L, Emblen JD, Van Hofwegen L, Sawatzky R, Meyerhoff H. An integrative review of the concept of spirituality in the health sciences. West J Nurs Res. 2004;26(4):405–28.View ArticlePubMedGoogle Scholar
  29. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15.View ArticlePubMedGoogle Scholar
  30. Bonvicini L, Candela S, Evangelista A, Bertani D, Casoli M, Lusvardi A, et al. Public and private pregnancy care in Reggio Emilia Province: an observational study on appropriateness of care and delivery outcomes. BMC Pregnancy Childbirth. 2014;14:72.Google Scholar
  31. Hosaka Y, Bito S, Matsubara K, Aoki Y, Iwata S. Association between the number of blood cultures and appropriateness of care for suspected bacteremic urinary tract infection in the elderly. J Infect Chemother. 2011;17(3):341–50.View ArticlePubMedGoogle Scholar
  32. King R, Michelman M, Curran V, Bean J, Rowden P, Lindsey J. Patient-centered approach to ensuring appropriateness of care through blood management. South Med J. 2013;106(6):362–8.View ArticlePubMedGoogle Scholar
  33. Liang Y, Du F, Thompson IM, Turner BJ. Limited PSA testing in indigent men in South Texas: an appropriate care or missing a prevention opportunity? Cancer Epidemiol Biomark Prev. 2012;21(9):1489–96.View ArticleGoogle Scholar
  34. Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma. 2011;71(1):175–85.View ArticlePubMedGoogle Scholar
  35. Panella M, Marchisio S, Brambilla R, Vanhaecht K, Di Stanislao F. A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study. BMC Med. 2012;10:71.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Poulos CJ, Magee C, Bashford G, Eagar K. Determining level of care appropriateness in the patient journey from acute care to rehabilitation. BMC Health Serv Res. 2011;11:291.View ArticlePubMedPubMed CentralGoogle Scholar
  37. Sandella JM, Boulet JR, Langenau EE. An evaluation of cost and appropriateness of care as recommended by candidates on a national clinical skills examination. Teach Learn Med. 2012;24(4):303–8.View ArticlePubMedGoogle Scholar
  38. Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013;27(10):543–51.View ArticlePubMedGoogle Scholar
  39. Bateson D. Female genital mutilation and modification: providing sensitive and appropriate care. Medicine Today. 2013;14(3):60–3.Google Scholar
  40. Breivik H, Eisenberg E, O’Brien T. The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health. 2013;13:1229.View ArticlePubMedPubMed CentralGoogle Scholar
  41. Brien S, Gheihman G, Tse YK, Byrnes M, Harrison S, Dobrow MJ. A scoping review of appropriateness of care research activity in Canada from a health system-level perspective. Healthc Policy. 2014;9(4):48–61.PubMedPubMed CentralGoogle Scholar
  42. Brindis R, Goldberg SD, Turco MA, Dean LS. President’s page: quality and appropriateness of care: the response to allegations and actions needed by the cardiovascular professional. J Am Coll Cardiol. 2011;57(1):111–3.View ArticlePubMedGoogle Scholar
  43. Chen JJ. Implications for managed care for improving outcomes in Parkinson’s disease: balancing aggressive treatment with appropriate care. Am J Manag Care. 2011;17(Suppl 12):S322–7.PubMedGoogle Scholar
  44. D’Alleyrand JCG, O’Toole RV. The evolution of damage control orthopedics. Current evidence and practical applications of early appropriate care. Orthop Clin North Am. 2013;44(4):499–507.View ArticlePubMedGoogle Scholar
  45. Sharpe VA, Uchendu US. Ensuring appropriate care for LGBT veterans in the veterans health administration. Hast Cent Rep. 2014;44:S53–5.View ArticleGoogle Scholar
  46. Ackermann E. Barriers to “appropriate care” in general practice. Med J Aust. 2012;197(2):76–7.View ArticlePubMedGoogle Scholar
  47. Fuchs VR. The doctor’s dilemma - what is “appropriate” care? N Engl J Med. 2011;365(7):585–7.View ArticlePubMedGoogle Scholar
  48. Hubbard J. Adjuvant chemotherapy in colon cancer: ageism or appropriate care? J Clin Oncol. 2011;29(24):3209–10.View ArticlePubMedGoogle Scholar
  49. Lippi G, Favaloro EJ. Laboratory diagnostics and appropriate care of people with haemophilia. Haemophilia. 2011; doi:https://doi.org/10.1111/j.1365-2516.2011.02528.x.
  50. Schoormans D, Sprangers MAG, Mulder BJM. Future challenges in providing appropriate care for adults with congenital heart disease. Int J Cardiol. 2013;168(3):3115–6.View ArticlePubMedGoogle Scholar
  51. Anstey MH, Adams JL, McGlynn EA. Perceptions of the appropriateness of care in California adult intensive care units. Crit Care. 2015;19(1):51.View ArticlePubMedPubMed CentralGoogle Scholar
  52. Barber CE, Patel JN, Woodhouse L, Smith C, Weiss S, Homik J, et al. Development of key performance indicators to evaluate centralized intake for patients with osteoarthritis and rheumatoid arthritis. Arthritis Res Ther. 2015;17(1):322.Google Scholar
  53. Bradford D, Hansen D, Karunanithi M. Making an APPropriate Care Program for Indigenous Cardiac Disease: Customization of an Existing Cardiac Rehabilitation Program. Stud Health Technol Inform. 2015;216:343-7.Google Scholar
  54. Broekhuis SM, Van Dijk WD, Giesen P, Pavilanis A. Walk-in clinics in Québec, Canada: patients and doctors do not agree on appropriateness of visits. Fam Pract. 2014;31(1):92–101.View ArticlePubMedGoogle Scholar
  55. Kazandjian VA, Lipitz-Snyderman A. HIT or miss: the application of health care information technology to managing uncertainty in clinical decision making. J Eval Clin Pract. 2011;17(6):1108–13.View ArticlePubMedGoogle Scholar
  56. Korst LM, Feldman DS, Bollman DL, Fridman M, El Haj IS, Fink A, et al. Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care. Am J Obstet Gynecol. 2015;213(4):527.e1–527.e12.Google Scholar
  57. Korst LM, Feldman DS, Bollman DL, Fridman M, El Haj IS, Fink A, et al. Variation in childbirth services in California: a cross-sectional survey of childbirth hospitals. Am J Obstet Gynecol. 2015;213(4):523.e1–8.Google Scholar
  58. Lin GA, Harris IS. Can appropriate use criteria lead to appropriate care? Circ Cardiovasc Qual Outcomes. 2015;8(1):4–5.View ArticlePubMedGoogle Scholar
  59. Martin SS. Exploring discrimination in American health care system: perceptions/experiences of older Iranian immigrants. J Cross-Cult Gerontol. 2012;27(3):291–304.View ArticlePubMedGoogle Scholar
  60. Mataoui F, Kennedy SL. Providing culturally appropriate care to American Muslims with cancer. Clin J Oncol Nurs. 2016;20(1):11–2.View ArticlePubMedGoogle Scholar
  61. McCormick WC. Culturally appropriate care is essential to quality care for older adults. Geriatr Nurs. 2014;35(6):486–7.View ArticlePubMedGoogle Scholar
  62. Mcfadden A, Renfrew MJ, Atkin K. Does cultural context make a difference to women’s experiences of maternity care? A qualitative study comparing the perspectives of breast-feeding women of Bangladeshi origin and health practitioners. Health Expect. 2013;16(4):e124–35.View ArticlePubMedGoogle Scholar
  63. Mochizuki Y, Iwasaki Y, Masaki H. The asian research & collaboration center for nursing & cultural studies in Japan. Int J Nurs Pract. 2012;18(SUPPL. 2):4–7.View ArticlePubMedGoogle Scholar
  64. Morgan S, Henderson KM, Tapley A, Scott J, Van Driel ML, Spike NA, et al. Pathology test-ordering behaviour of Australian general practice trainees: a cross-sectional analysis. Int J Qual Health Care. 2015;27(6):528–35.Google Scholar
  65. Newbrander W, Natiq K, Shahim S, Hamid N, Skena NB. Barriers to appropriate care for mothers and infants during the perinatal period in rural Afghanistan: a qualitative assessment. Global Public Health. 2014;9(SUPPL.1):S93–S109.View ArticlePubMedGoogle Scholar
  66. Paprica PA, Culyer AJ, Elshaug AG, Peffer J, Sandoval GA. FROM TALK to ACTION: POLICY STAKEHOLDERS, APPROPRIATENESS, and SELECTIVE DISINVESTMENT. Int J Technol Assess Health Care. 2015;31(4):236–40.View ArticlePubMedPubMed CentralGoogle Scholar
  67. Tasker A, Hughes A, Kelly M. Managing polytrauma: picking a way through the inflammatory cascade. Orthop Trauma. 2014;28(3):127–36.View ArticleGoogle Scholar
  68. Tolson D, Rolland Y, Andrieu S, Aquino J, Beard J, Benetos A, et al. International Association of Gerontology and Geriatrics: a global agenda for clinical research and quality of Care in Nursing Homes. J Am Med Dir Assoc. 2011;12(3):184–9.Google Scholar
  69. Tucker S, Brand C, Wilberforce M, Challis D. The balance of care approach to health and social care planning: Lessons from a systematic literature review. Health Serv Manag Res. 2013;26(1):18–28.View ArticleGoogle Scholar
  70. Vallier HA, Moore TA, Como JJ, Dolenc AJ, Steinmetz MP, Wagner KG, et al. Teamwork in trauma: system adjustment to a protocol for the Management of Multiply Injured Patients. J Orthop Trauma. 2015;29(11):e446–50.Google Scholar
  71. Vaucher C, Maillard MH, Froehlich F, Burnand B, Michetti P, Pittet V. Patients and gastroenterologists’ perceptions of treatments for inflammatory bowel diseases: do their perspectives match? Scand J Gastroenterol. 2016:1–6.Google Scholar
  72. Weinberg DS, Narayanan AS, Moore TA, Vallier HA. Prolonged resuscitation of metabolic acidosis after trauma is associated with more complications. J Orthop Surg Res. 2015;10(1):153.View ArticlePubMedPubMed CentralGoogle Scholar
  73. Brooks E, Novins DK, Noe T, Bair B, Dailey N, Lowe J, et al. Reaching rural communities with culturally appropriate care: a model for adapting remote monitoring to American Indian veterans with posttraumatic stress disorder. Telemed J E Health. 2013;19(4):272–7.Google Scholar
  74. Trinh NH, Hagan PN, Flaherty K, Traeger LN, Inamori A, Brill CD, et al. Evaluating patient acceptability of a culturally focused psychiatric consultation intervention for Latino Americans with depression. J Immigr Minor Health. 2014;16(6):1271–7.Google Scholar
  75. Trinh N, Hails K, Flaherty K, Chang T, Fava M, Yeung A. Lessons learned: implementation of a culturally focused psychiatric consultation service for Latino Americans and Asian Americans. J Health Care Poor Underserved. 2015;26(3):792–801.View ArticlePubMedGoogle Scholar
  76. Fanari Z, Abraham N, Hammami S, Doorey AJ. Aggressive measures to decrease door to balloon time may increase the incidence of unnecessary cardiac catheterization and delay appropriate care. Del Med J. 2015;87(9):276–9.PubMedGoogle Scholar
  77. Mancuso P, Valdmanis VG. Care appropriateness and health productivity evolution: a non-parametric analysis of the Italian regional health systems. Appl Health Econ Health Policy. 2016;14(5):595–607.View ArticlePubMedGoogle Scholar
  78. Matthie N, Jenerette C. Sickle cell disease in adults: developing an appropriate care plan. Clin J Oncol Nurs. 2015;19(5):562–8.View ArticlePubMedGoogle Scholar
  79. Mitchell RA, Stanger D, Shuster C, Telford J, Lam E, Enns R. Repeat endoscopic ultrasound-guided fine-needle aspiration in patients with suspected pancreatic cancer: diagnostic yield and associated change in access to appropriate care. Can J Gastroenterol Hepatol. 2016;2016:7678403.PubMedPubMed CentralGoogle Scholar
  80. Pape HC, Andruszkow H, Pfeifer R, Hildebrand F, Barkatali BM. Options and hazards of the early appropriate care protocol for trauma patients with major fractures: towards safe definitive surgery. Injury. 2016;47(4):787–91.View ArticlePubMedGoogle Scholar
  81. Reich MS, Dolenc AJ, Moore TA, Vallier HA. Is early appropriate care of axial and femoral fractures appropriate in multiply-injured elderly trauma patients? J Orthop Surg Res. 2016;11(1):106.View ArticlePubMedPubMed CentralGoogle Scholar
  82. Dello Russo S, Mascia D, Morandi F. Individual perceptions of HR practices, HRM strength and appropriateness of care: a meso, multilevel approach. Int J Hum Resour Man. 2016;Google Scholar
  83. Schneider F, Poidevin A, Riehm S, Herbrecht JE, Guillot M. Liver transplantation in case of acetaminophen poisoning: importance of assessment of the colon if arterial lactate increases despite appropriate care. Transplantation. 2014;98(2):e10–1.View ArticlePubMedGoogle Scholar
  84. Vallier HA, Dolenc AJ, Moore TA. Early appropriate care: a protocol to standardize resuscitation assessment and to expedite fracture care reduces hospital stay and enhances revenue. J Orthop Trauma. 2016;30(6):306–11.View ArticlePubMedGoogle Scholar
  85. Wynell-Mayow W, Guevel B, Quansah B, O’Leary R, Carrothers AD. Cambridge Polytrauma pathway: are we m aking appropriately guided decisions? Injury. 2016;47(10):2117–21.Google Scholar
  86. Brooks E, Spargo G, Yellowlees P, O’Neill P, Shore JH. Integrating culturally appropriate care into telemental health practice. In Myers K, Turvey CL editors. Telemental Health: Clinical, Technical, and Administrative Foundations for Evidenced-Based Practice. Waltham: Elsevier; 2013. pp 63-79.Google Scholar
  87. Pittet V, Maillard MH, Lauvergeon S, Timmer M, Michetti P, Froehlich F, et al. Acceptance of inflammatory bowel disease treatment recommendations based on appropriateness ratings: do practicing gastroenterologists agree with experts? J Crohns Colitis. 2015;9(2):132–9.Google Scholar
  88. Anonymous Effective care. In: The Dartmouth atlas of health care. 2014. http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2939. Accessed 5 Sept 2014.
  89. Reeve J, Dowrick CF, Freeman GK, Gunn J, Mair F, May C, et al. Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions. JRSM Short Rep. 2013;4(12):2042533313510155.Google Scholar
  90. Reeve J. Interpretive medicine: supporting generalism in a changing primary care world. Occas Pap R Coll Gen Pract. 2010;(88):1–20, v.Google Scholar
  91. Anonymous Preference-sensitive care. In: The Dartmouth atlas of health care. 2014. http://www.dartmouthatlas.org/keyissues/issue.aspx?con=2938. Accessed 5 Sept 2014.

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© The Author(s). 2017