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

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.


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 [2][3][4][5][6] 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, costeffectiveness criteria for service coverage and pay-forperformance 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 [12][13][14]. 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 [16][17][18] and retrospectively by assessing guideline adherence for specific conditions [18][19][20]. 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 peerreviewed 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 [24][25][26]. 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.

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,.

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 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

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).

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 [34-36, 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]. 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, 59-63, 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].

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: evidencebased 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, costeffectiveness, 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 decisionmaking 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 diseasespecific 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 Fig. 6 Resource use 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 evidencebased 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, 59-63, 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, patientcenteredness, 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.