responsibility of NHLBI and other components of the National Institutes of Health (NIH) typically ends with clinical trials designed to demonstrate a technology's safety and efficacy.

An emerging technology is rarely scrutinized to the degree reflected in this report and the previous NHLBI evaluations, and none has been so publicly examined this many years in advance of its routine clinical use. The committee is thus able to express its concerns about inappropriate use becoming a problem area for MCSSs and to suggest how those involved with MCSS development and diffusion can minimize the likelihood of inappropriate use. Further, the interim period until general, widespread MCSS use begins provides an unprecedented opportunity to debate, decide upon, and implement a group of mechanisms to promote their appropriate use.

WHAT APPROPRIATE TECHNOLOGY USE IS

The term “appropriateness” has no special definition when applied to the provision of health care services. Appropriateness of use can perhaps best be explained by viewing it as one important aspect of the quality of care, where quality is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990b, p. 21).

Using this definition of quality of care, appropriateness is one of the elements of quality that links health services to “desired health outcomes”; it is “using what works” (Berwick, 1989). Clinical trials and technology assessments help to define what works by determining efficacy, effectiveness, risks, and cost-effectiveness. All of these are important measures in providing quality care or, as the Institute of Medicine (IOM) definition noted, care that is “consistent with current professional knowledge.”

This dissection of quality care into small elements reinforces the importance of appropriate care. Appropriateness becomes the bottom line—using what works, only when it is expected to work, and only with those for whom it is expected to work. Consideration of cost leads to the additional conclusion that appropriate care uses resources to produce more improvement in health outcome than could be achieved by alternative uses of those same resources. Later sections of this chapter explore issues relevant to “using what works.”

Several groups have studied appropriateness of use of specific technologies. For example, both Wennberg and colleagues (1988) and Chassin and his colleagues at the RAND Corporation (1987) have focused on variations in physician practice patterns, in particular the overuse or underuse of surgical procedures. Appropriateness is a concept that is applicable to any type of health care technology or service, whether a drug, medical device, or medical or surgical intervention and whether new or routinely used.



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