Biomaterial Database

Medicare Peer Review Organization preprocedure review criteria. An analysis of criteria for three procedures. 1991

S E Kellie, and J T Kelly

Office of Quality Assurance, American Medical Association, Chicago, Ill.

The Medicare Peer Review Organization (PRO) program includes preprocedure review using explicit criteria to assess the appropriateness of specific procedures. This study evaluates the variability in the PRO preprocedure criteria for the three procedures most frequently reviewed by PROs: carotid endarterectomy, cataract removal, and cardiac pacemaker implants. In August 1989, the PRO review criteria were received from the Health Care Financing Administration. To provide a reference point for reviewing the PRO criteria, national practice guidelines for these three procedures were identified. Wide variability was demonstrated in the PRO procedure-specific carotid endarterectomy and cataract removal review criteria among PROs, and the criteria differed significantly from the identified practice guidelines. The criteria for cardiac pacemaker implants were somewhat less variable, and were based, to varying degrees, on practice guidelines developed by the American College of Cardiology (ACC). Greater attention is needed to improve the development of review criteria, including the use of relevant practice guidelines, to ensure that review criteria are optimal.

UI	MeSH Term	Description	Entries
D010138	Pacemaker, Artificial	A device designed to stimulate, by electric impulses, contraction of the heart muscles. It may be temporary (external) or permanent (internal or internal-external).	Cardiac Pacemaker, Artificial,Artificial Cardiac Pacemaker,Artificial Cardiac Pacemakers,Artificial Pacemaker,Artificial Pacemakers,Cardiac Pacemakers, Artificial,Pacemaker, Artificial Cardiac,Pacemakers, Artificial,Pacemakers, Artificial Cardiac
D010818	Practice Patterns, Physicians'	Patterns of practice related to diagnosis and treatment as especially influenced by cost of the service requested and provided.	Clinical Practice Patterns,Physician's Practice Patterns,Clinical Practice Pattern,Pattern, Clinical Practice,Patterns, Clinical Practice,Practice Pattern, Clinical,Practice Patterns, Clinical,Practice Patterns, Physician's,Prescribing Patterns, Physician,Physician Practice Patterns,Physician Prescribing Pattern,Physician Prescribing Patterns,Physician's Practice Pattern,Physicians' Practice Pattern,Physicians' Practice Patterns,Practice Pattern, Physician's,Practice Pattern, Physicians',Practice Patterns, Physician,Prescribing Pattern, Physician
D011366	Professional Review Organizations	Organizations representing designated geographic areas which have contracts under the PRO program to review the medical necessity, appropriateness, quality, and cost-effectiveness of care received by Medicare beneficiaries. Peer Review Improvement Act, PL 97-248, 1982.	PRO Professional Review Organizations,PSRO,Peer Review Organizations,Professional Standards Review Organizations,Utilization and Quality Control Peer Review Organizations,Organizations, Peer Review,Organizations, Professional Review,Review Organizations, Professional,Organization, Peer Review,Organization, Professional Review,Peer Review Organization,Professional Review Organization
D002340	Carotid Artery Diseases	Pathological conditions involving the CAROTID ARTERIES, including the common, internal, and external carotid arteries. ATHEROSCLEROSIS and TRAUMA are relatively frequent causes of carotid artery pathology.	Carotid Atherosclerosis,Common Carotid Artery Disease,Internal Carotid Artery Disease,Arterial Diseases, Carotid,Arterial Diseases, Common Carotid,Arterial Diseases, External Carotid,Arterial Diseases, Internal Carotid,Atherosclerotic Disease, Carotid,Carotid Artery Disorders,Carotid Atherosclerotic Disease,Common Carotid Artery Diseases,External Carotid Artery Diseases,Internal Carotid Artery Diseases,Arterial Disease, Carotid,Artery Disease, Carotid,Artery Diseases, Carotid,Artery Disorder, Carotid,Artery Disorders, Carotid,Atherosclerotic Diseases, Carotid,Carotid Arterial Disease,Carotid Arterial Diseases,Carotid Artery Disease,Carotid Artery Disorder,Carotid Atheroscleroses,Carotid Atherosclerotic Diseases,Disorders, Carotid Artery
D002387	Cataract Extraction	The removal of a cataractous CRYSTALLINE LENS from the eye.	Enzymatic Zonulolysis,Phakectomy,Cataract Extractions,Enzymatic Zonulolyses,Extraction, Cataract,Extractions, Cataract,Phakectomies,Zonulolyses, Enzymatic,Zonulolysis, Enzymatic
D004691	Endarterectomy	Surgical excision, performed under general anesthesia, of the atheromatous tunica intima of an artery. When reconstruction of an artery is performed as an endovascular procedure through a catheter, it is called ATHERECTOMY.	Thromboendarterectomy,Endarterectomies,Thromboendarterectomies
D005069	Evaluation Studies as Topic	Works about studies that determine the effectiveness or value of processes, personnel, and equipment, or the material on conducting such studies.	Critique,Evaluation Indexes,Evaluation Methodology,Evaluation Report,Evaluation Research,Methodology, Evaluation,Pre-Post Tests,Qualitative Evaluation,Quantitative Evaluation,Theoretical Effectiveness,Use-Effectiveness,Critiques,Effectiveness, Theoretical,Evaluation Methodologies,Evaluation Reports,Evaluation, Qualitative,Evaluation, Quantitative,Evaluations, Qualitative,Evaluations, Quantitative,Indexes, Evaluation,Methodologies, Evaluation,Pre Post Tests,Pre-Post Test,Qualitative Evaluations,Quantitative Evaluations,Report, Evaluation,Reports, Evaluation,Research, Evaluation,Test, Pre-Post,Tests, Pre-Post,Use Effectiveness
D006278	Medicare	Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)	Health Insurance for Aged and Disabled, Title 18,Insurance, Health, for Aged and Disabled,Health Insurance for Aged, Disabled, Title 18,Health Insurance for Aged, Title 18
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D001157	Arterial Occlusive Diseases	Pathological processes which result in the partial or complete obstruction of ARTERIES. They are characterized by greatly reduced or absence of blood flow through these vessels. They are also known as arterial insufficiency.	Arterial Obstructive Diseases,Arterial Occlusion,Arterial Obstructive Disease,Arterial Occlusions,Arterial Occlusive Disease,Disease, Arterial Obstructive,Disease, Arterial Occlusive,Obstructive Disease, Arterial,Occlusion, Arterial,Occlusive Disease, Arterial