What is appropriate care? From clinical effectiveness to a more integrated understanding

Background: Health care improvement efforts should be aligned in order to make a meaningful impact on health system improvement. Appropriate care delivery could be a unifying goal to help coordinate efforts to improve health outcomes and ensure system sustainability. A better awareness 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 health care delivery practices.

Purpose: To examine the current understanding of appropriate care by categorizing its use and definitions in recently published literature and propose a more integrated framework for appropriate care delivery based on the principles of clinical effectiveness, justice, and patient autonomy.

Study Design: Review of the definitions and parameters of use of appropriate care in English language peer-reviewed articles that were published between 2011 and 2014. We systematically compared how articles characterized appropriate care and its scope of applicability according to descriptive elements, (i.e., determinant of appropriateness, perspective of appropriateness, health care setting and type of care delivered) and ethical elements, (i.e., clinical effectiveness, justice (cost, equity, and resource use), and respect for patient autonomy (respect for patient preferences and values). Appropriate care elements were compared using frequency counts. Emerging patterns and gaps were then mapped according to our developed appropriate care framework to inform recommendations for a more integrated understanding of appropriate care.

Principle Findings: Definitions and use of appropriate care varied. Most appropriate care articles focused on single episode, condition/ procedure-specific, inpatient care and appropriateness was most commonly based on health-related outcomes, followed by guideline adherence and physician discretion. All articles included clinical effectiveness components, and a majority of articles included resource efficiency concerns in their understanding of appropriate care. However, considerations of cost, equity, and respect for patient preferences and values tended to be neglected overall and especially underrepresented in empirical studies.

Conclusion: No universal understanding of appropriate care yet exists; however, clinical effectiveness seems to be universally considered a vital element of appropriate care. The overall use of clinical outcomes and guidelines to guide appropriate care delivery represents a reliance on evidence-based measures. An integrated framework for appropriate care that includes elements of fair distribution and respect for patients’ self-defined vision of health and well-being could improve health care delivery and provide an aligned vision for health care system improvement and sustainability.