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Biomedical subjects

S J Bernstein

Publications and source records attributed to S J Bernstein.

At least 37 records · Page 2Linked to original sources
PubMed1999

Differences in menstrual bleeding characteristics, functional status, and attitudes toward menstruation in three groups of women.

This report examines differences in bleeding characteristics, functional status, and attitudes toward menstruation among three groups of women: (1) women who complain of abnormal uterine bleeding (AUB), (2) women who have similar menstrual patterns as those complaining of AUB but who do not perceive themselves to have abnormal bleeding, and (3) women without evidence of prolonged or excessive bleeding. Women who complain of AUB and women with heavy bleeding but not complaining of AUB, although similar on two important menstrual symptoms (very heavy bleeding or episodes of unusually heavy bleeding) differ on a number of other menstrual characteristics, including the frequency of short cycles, the probability of having an abnormally long period, and reporting of unusually heavy bleeding lasting longer than 1 day. Whether women reported concerns with menstruation or not, the majority of women in this analysis had fairly negative attitudes toward menstruation. However, this negativity toward menstruation did not translate into women wanting a hysterectomy, even for those with heavy bleeding. The major difference among the three groups of women was the strong negative effect of AUB on functional status. A majority of women complaining of AUB reported that the bleeding interfered significantly with their daily routine, making them unable to function at work and at home. These results suggest that although the main complaint of women with AUB is very heavy bleeding, a number of other specific menstrual characteristics differentiate women with AUB from other women with very heavy bleeding who do not perceive the bleeding to be problematic. The complaint of AUB appears to be related to how significantly bleeding affects daily functioning. Therefore, an important factor to assess when considering treatment of AUB is the extent to which bleeding symptoms significantly affect functional status.

Adult↗
PubMed1999

Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group.

OBJECTIVE: To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES: Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS: Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS: Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.

Adult↗
PubMed1998

The reproducibility of a method to identify the overuse and underuse of medical procedures.

BACKGROUND: To assess the overuse and underuse of medical procedures, various methods have been developed, but their reproducibility has not been evaluated. This study estimates the reproducibility of one commonly used method. METHODS: We performed a parallel, three-way replication of the RAND-University of California at Los Angeles appropriateness method as applied to two medical procedures, coronary revascularization and hysterectomy. Three nine-member multidisciplinary panels of experts were composed for each procedure by stratified random sampling from a list of experts nominated by the relevant specialty societies. Each panel independently rated the same set of clinical scenarios in terms of the appropriateness of the relevant procedure on a risk-benefit scale ranging from 1 to 9. Final ratings were used to classify the procedure in each scenario as necessary or not necessary (to evaluate underuse) and inappropriate or not inappropriate (to evaluate overuse). Reproducibility was measured by overall agreement and by the kappa statistic. The criteria for underuse and overuse derived from these ratings were then applied to real populations of patients who had undergone coronary revascularization or hysterectomy. RESULTS: The rates of agreement among the three coronary-revascularization panels were 95, 94, and 96 percent for inappropriate-use scenarios and 93, 92, and 92 percent for necessary-use scenarios. Agreement among the three hysterectomy panels was 88, 70, and 74 percent for inappropriate-use scenarios. Scenarios involving necessary use of hysterectomy were not assessed. The three-way kappa statistic to detect overuse was 0.52 for coronary revascularization and 0.51 for hysterectomy. The three-way kappa statistic to detect underuse of coronary revascularization was 0.83. Application of individual panels' criteria to real populations of patients resulted in a 100 percent variation in the proportion of cases classified as inappropriate and a 20 percent variation in the proportion of cases classified as necessary. CONCLUSIONS: The appropriateness method is far from perfect. Appropriateness criteria may be useful in comparing levels of appropriate procedures among populations but should not by themselves be used to direct care for individual patients.

Delphi Technique↗
PubMed1997

Coronary angiography and angioplasty after acute myocardial infarction.

PURPOSE: To assess the data that support the use of coronary angiography and angioplasty after acute myocardial infarction, that identify the risks of these procedures, and that analyze their use and costs. DATA SOURCES: English-language articles published between 1970 and June 1995 identified through a search of the MEDLINE database. STUDY SELECTION: Studies that contained information about benefits, risks, use, and costs of coronary angiography and angioplasty after acute myocardial infarction. DATA EXTRACTION: Descriptive and analytic data from each study were collected. DATA SYNTHESIS: The outcome for patients who have complications of myocardial infarction (such as shock) is poor. Such patients usually undergo angiography, although the evidence that supports this practice is weak. Preliminary data suggest that patients who immediately have angiography and angioplasty after acute myocardial infarction have better outcomes than do patients who receive thrombolytic therapy with angioplasty only for specific indications in experienced centers. After the acute phase of myocardial infarction, patients who have noninvasive evidence of persistent or recurrent ischemia are believed to benefit from angiography. In the remaining patients, however, angiography after myocardial infarction has not been shown to be beneficial. Coronary angiography is done in 30% to 81% of patients after acute myocardial infarction in different settings and regions; for many of these patients, the benefit is questionable. Better outcomes are not always associated with more frequent use of the procedure. In the United States, catheterizations after myocardial infarction cost approximately $1 billion per year. CONCLUSIONS: Although many patients benefit from angiography and angioplasty after myocardial infarction, others probably do not. Substantial resources are at stake.

Angioplasty↗
PubMed1997

Waiting for coronary revascularization: a comparison between New York State, The Netherlands and Sweden.

OBJECTIVE: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. METHODS: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. RESULTS: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P < 0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P < 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. CONCLUSIONS: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved.

Angina Pectoris↗
PubMed1997

CABG in chronic stable angina pectoris patients: indications and outcomes (SECOR/SBU). Swedish Societies for Cardiology, Thoracic Radiology and Thoracic surgery/Swedish Council for Technology Assessment in Health Care.

OBJECTIVE: In order to ascertain the reasons why coronary revascularisation is performed, the appropriateness of these procedures and their outcomes, a national collaborative study encompassing 7 of 8 hospitals performing CABG in Sweden was undertaken. This article presents the indications and outcomes in the largest intervention group, chronic stable angina pectoris treated by first time CABG. METHODS: A prospective multi-centre study was carried out during a 3.5 month period in each centre. Patients (1039) with chronic stable angina pectoris undergoing first time CABG were enrolled. Patients' quality of life was recorded at the time they underwent angiography and again 6 months post-operatively. Mortality and serious peri-and post-operative complications were recorded. The study was designed and carried out by an independent government agency, the Swedish Council for Technology Assessment in Health Care (SBU) with a project group of representatives for the Swedish Societies for Cardiology, Thoracic Radiology and Thoracic Surgery. RESULTS: Median age was 66 years. A total of 80% were males. The mortality rates at 30 days and 6 months were 1.0 and 1.9%, respectively. A balloon pump was used for 0.9% of patients and 1.4% of them were on a respirator for more than 24 h. At recruitment, 43.9% of the patients reported having severe angina (CCS II/IV), 70.1% had angina > or = 3 times per week, and 53.1% used sublingual nitrates > or = 3 times per week. The corresponding results at 6 months were 6.7, 10.5 and 3.3%, respectively. Patient satisfaction with operative treatment was high. In comparison with the pre-operative status, quality of life was markedly improved after surgery. CONCLUSION: This study shows that CABG in chronic stable angina pectoris yields good outcomes with a low mortality and morbidity and a high degree of patient satisfaction and quality of life.

Adult↗
PubMed1997

Validating quality indicators for hospital care.

BACKGROUND: Many of the indicators used to monitor the quality of hospital care are resource intensive and ineffective. Furthermore, current efforts to develop new indicators for report cards are generally directed at the evaluation of health plans and are not constructed to help providers (physician groups, hospitals, and health plans that contract to provide care to patients) find and fix problems with the quality of care at their organizations. FOUR QUESTIONS: Before using an indicator, four questions should be posed: (1) When cases identified by the indicator are examined, can one find a set of definable and preventable processes of care known to lead to a bad outcome? (2) Can a review instrument be created that will allow providers to identify which process problems are present? (3) Are there substantially more process problems in those cases identified by the indicator than in those cases not identified by the indicator, and can the sensitivity and specificity of the indicator be defined? and (4) Is the indicator primarily useful for quality improvement efforts by a provider, or is it also useful as an external measure of quality across providers? A FOUR-STEP FRAMEWORK: Four corresponding steps comprise an efficient validation method to produce indicators that detect deficiencies in an important process-outcome continuum, help produce the tools to find the deficiencies, document the efficiency of using the indicator to search for process problems, and define the appropriate use of the indicator. Use of such validated indicators, and the information about their utility, would allow providers to optimize the impact of money spent on quality improvement efforts.

Hospital Administration↗
PubMed1997

The decision-making process for the treatment of abnormal uterine bleeding.

This pilot study was conducted to investigate the treatment decision-making process of patients and physicians for abnormal uterine bleeding (AUB). Frequently, women with AUB are referred for hysterectomy without diagnostic workup, alternative therapeutic management, or patient input (i.e., patient treatment preferences). Variations in treatment strategies used for patients may be related to a number of factors external to the patient's underlying disease. However, little is known about which factors are most influential or about the extent to which they influence physicians' and patients' decisions. We prospectively followed the management and treatment of 52 women with complaints of AUB and examined differences in treatment among these patients. Extensive previsit interviews were conducted with these women to identify each patient's symptoms, health status, functional status, and preferences for and expectations of treatment. We then conducted telephone interviews within a week of the visit and again 9-12 months later to determine the treatment plan, patient level of participation in and satisfaction with the treatment, symptoms, and functional status. Overall, our findings suggest that patients want to be involved in making treatment decisions and that when women were presented with alternatives to hysterectomy, many chose alternative medical therapy or other surgical procedures. In addition, women reported that these alternative treatments produced significant improvement in symptom intensity and functioning. Increased patient participation in decision making enhanced patient satisfaction. These findings suggest that hysterectomy rates may be decreased by offering women alternative treatments and by finding ways to increase women's participation in their treatment decisions.

Adolescent↗
PubMed1997

Under use of coronary angiography: application of a clinical method.

OBJECTIVE: To estimate the extent of under use of coronary angiography and to determine whether women, ethnic minorities and poor and uninsured patients are less likely than their counterparts to receive necessary coronary angiography. DESIGN: Retrospective cohort study employing chart review and patient interviews. SETTING: Four teaching hospitals: three government owned (public) and one private university medical center in Los Angeles, California. PATIENTS: Three hundred and fifty two patients who had a positive exercise stress test between 1 January 1990 and 30 June 1991 and met explicitly defined criteria for the necessity of coronary angiography established by a multidisciplinary expert panel. MAIN OUTCOME MEASURES: Percentage of patients who received necessary coronary angiography within 3 and 12 months following exercise stress testing, adjusted for demographic and clinical characteristics using logistic regression. RESULTS: Overall 43% received necessary coronary angiography within 3 months and 56% within 12 months of the stress test. Women were less likely than men to receive necessary coronary angiography. Adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI) 0.34-0.90 for angiography within 3 months of the stress test; AOR 0.47, 95% CI 0.29-0.77 for angiography within 12 months of the stress test. Public hospital patients underwent necessary coronary angiography less often than private hospital patients. AOR 0.40, 95% CI 0.23-0.79 for within 3 months; AOR 0.52, 95% CI 0.30-0.91 for within 12 months. CONCLUSIONS: Under use of coronary angiography can be measured and occurs to a significant degree. It is important to develop standards of quality to address and safeguard against under use of necessary medical care.

Aged↗
PubMed1997

Setting standards for effectiveness: a comparison of expert panels and decision analysis.

OBJECTIVE: To compare criteria for coronary revascularization developed by the expert panel process and by decision analysis. METHOD: We reviewed the medical records of 3080 chronic stable angina patients who either underwent coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) and determined the agreement between appropriateness ratings made by two expert physician panels, one from the United States and the second from The Netherlands. We also evaluated the agreement between these panels' appropriateness ratings and a decision analytic model's effectiveness categories. RESULTS: There was poor agreement between U.S. and Dutch panel appropriateness ratings for PTCA (kappa = 0.03) and slight agreement for bypass surgery (kappa = 0.18). Dutch ratings had substantial agreement with the decision analytic models effectiveness categories for both PTCA and CABG (kappa = 0.83 and 0.79, respectively) whereas there was no systematic agreement between U.S. ratings and the decision analytic model for PTCA and poor agreement for CABG (kappa = 0.00 and 0.18, respectively). CONCLUSIONS: Although the level of agreement between expert panels and decision analysis on when a procedure is appropriate or effective may vary by procedure and the strength of the scientific evidence, we found that Dutch physicians agree much more strongly with decision analysis than U.S. physicians.

Angioplasty, Balloon, Coronary↗
PubMed1997

Indications for coronary revascularisation: a Dutch perspective.

OBJECTIVE: To assess the appropriateness of indications for coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA). METHODS: A modified Delphi group judgement process with input from a panel of six interventional cardiologists and six cardiopulmonary surgeons. There was one clinician from each of the 12 tertiary referral heart centres in The Netherlands. MAIN OUTCOME MEASURE: Ratings by panel members, on a 1 to 9 scale, of indications presented as a choice between two treatments (CABG v medical treatment, PTCA v medical treatment, and CABG v PTCA) for 1182 model cases. Each case represented a unique combination of clinical features in terms of symptoms, medical history, and results of tests. Ratings were analysed with respect to degree of agreement among panelists, degree of appropriateness of indications, and panel's preference for invasive or medical treatment. RESULTS: The panel agreed on 58.6% and disagreed on 3.2% of the indications. The panel opted for invasive treatment in 48.2% and medical treatment in 22.8%, and had no clear preference for either method in 29.0% of the cases. When compared with medical treatment, CABG was more often rated appropriate than PTCA: 35.4% v 21.6% (P < 0.001). Panel scores depended on severity of anatomical disease. For instance, for 51.5% of the model cases with one-vessel disease not including the proximal left anterior descending artery, the panel preferred medical treatment to invasive treatment, while the latter was preferred in 18% of the cases. In cases with type C lesions, the panel frequently rated PTCA as inappropriate. Panel scores were also affected by nonclinical factors. Cardiologists and surgeons rated the procedure of their own specialty higher than the alternative invasive intervention. CONCLUSIONS: The panel method yields logically consistent scores of the appropriateness of indications for carrying out medical procedures. It may be an aid in formulating clinical practice guidelines.

Angioplasty, Balloon, Coronary↗
PubMed1997

The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands.

OBJECTIVE: To determine the appropriateness of intention to treat decisions concerning coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for patients with coronary artery disease in The Netherlands. DESIGN: Prospective study of intention to treat decisions using a computerised expert system. SETTING: "Presentation" sessions in 10 tertiary referral heart centres in 1992. PATIENTS: 3207 consecutive patients: 1618 CABG and 1589 PTCA candidates. MAIN OUTCOME MEASURE: Percentage of invasive treatment decisions rated appropriate, uncertain, or inappropriate by the expert system. RESULTS: PTCA decisions were common for patients with one-vessel disease and CABG decisions for patients with three-vessel and left main disease. PTCA decisions outnumbered CABG decisions in acute myocardial infarction. Of CABG decisions, 84% were rated appropriate, 12% uncertain, and 4% inappropriate. The proportions for PTCA decisions were 39% appropriate, 31% uncertain, and 29% inappropriate. Type C lesion was the main determinant of inappropriateness of PTCA decisions. If type C lesions were downgraded to type A/B lesions the rate of inappropriate PTCA decisions dropped to 6%. CONCLUSIONS: Clinicians in tertiary referral centres in The Netherlands favoured CABG if vessel disease was extensive or involved the left main artery, and PTCA for patients with less extensive disease and with acute myocardial infarction. Few CABG decisions were inappropriate. The main determinant of inappropriateness of PTCA decisions was its intended use in patients with type C lesions.

Aged↗
PubMed1996

Panellist consistency in the assessment of medical appropriateness.

Where information about the appropriateness of a surgical procedure is lacking, expert panels have been used to establish guidelines for medical practitioners. Such a panel was convened to assess the appropriateness of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery in the Netherlands. The panel, consisting of interventional cardiologists and cardiothoracic surgeons, used a modified Delphi process to rate 1126 clinical indications over two rounds. This article describes the degree of change in both agreement amongst members and in the appropriateness ratings over the two rounds, and examines the internal consistency of the ratings of individual panellists. Over the two rounds, agreement increased. Although most appropriateness ratings remained unchanged, there was significant movement from equivocal ratings to determinate ratings. While individual members showed some degree of inconsistency in their scoring, the panel as a whole scored very consistently. The observed changes in appropriateness were consistent with expectations, showing that the appropriateness method is used logically and consistently by panellists.

Angioplasty, Balloon, Coronary↗
PubMed1996

Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures.

The authors compare the appropriateness ratings and mutual influence of panelists from different specialties rating a comprehensive set of indications for six surgical procedures. Nine-member panels rated each procedure: abdominal aortic aneurysm surgery, carotid endarterectomy, cataract surgery, coronary angiography, and coronary artery bypass graft surgery/percutaneous transluminal coronary angioplasty (common panel). Panelists individually rated the appropriateness of indications at home and then discussed and re-rated the indications during a 2-day meeting. Subsequently, they rated the necessity of those indications scored by the group as appropriate. There were 45 panelists, including specialists (either performers of the procedure or members of a related specialty) and primary care providers, all drawn from nominations by their respective specialty societies. Main outcome measures included: individual panelists' mean ratings over all indications, mean change and conformity scores between rounds of ratings, and the percentage of audited actual procedures rated appropriate or necessary. Performers had the highest mean ratings, followed by physicians in related specialties, trailed by primary care providers. One fifth of all actual procedures were for indications rated appropriate by performers and less than appropriate by primary care providers. At the panel meetings, primary care providers and related specialists showed no greater tendency to be influenced by other panelists than did performers. Multispecialty panels provide more divergent viewpoints than panels composed entirely of performers. This divergence means that fewer actual procedures are deemed performed for appropriate or necessary indications.

Angioplasty, Balloon, Coronary↗
PubMed1995

A matter of opinion about hysterectomies: experts' and practicing community gynecologists' ratings of appropriateness.

The degree to which national expert panel survey ratings of the appropriateness of hysterectomy differed from those of a random sample of practicing community gynecologists was determined. Community gynecologists rated hysterectomy as more appropriate on six of eight cervical dysplasia scenarios. Experts agreed among themselves on 19 of 32 indications (intraclass correlation coefficient = 0.66); community gynecologists agreed on 12 of 32 indications (intraclass correlation coefficient = 0.50). Although few differences of opinion existed between experts and community gynecologists, for common clinical scenarios there was a large variation of opinion about the appropriateness of hysterectomy within each group. For areas of clinical uncertainty in which experts' opinions are used in guideline development, additional measures such as process of care, quality of life, and patient preference should be included in discussions about guidelines.

Adult↗
PubMed1994

Comparison of the appropriateness of coronary angiography and coronary artery bypass graft surgery between Canada and New York State.

OBJECTIVE: To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada. DESIGN: Retrospective randomized medical record review. SETTING: All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery. PATIENTS: All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected. MAIN OUTCOME MEASURES: Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures. RESULTS: For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%; P < .001) and CABG (6% vs 14%; P < .001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%; P = .023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (P < .0001). CONCLUSIONS: Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination.

Aged↗
PubMed1994

Measuring the necessity of medical procedures.

This is a report on the extension of the concept of the appropriateness of a procedure to the necessity, or crucial importance, of that procedure. To state that a procedure is crucial means that withholding the procedure would be deleterious to the patient's health. Appropriateness and necessity ratings for six procedures were obtained using a modified Delphi panel process developed in earlier work. Panels were composed of practicing clinicians who were recognized leaders in their fields. The panels included both performers and nonperformers of the procedure under discussion. For most procedures and panelists, necessity was related to appropriateness, but was distinct from it. The proportion of indications for which the procedure was crucial varied in clinically consistent ways both among and within procedures. However, panelists did not achieve a consensus on necessity. Further research is suggested to refine the method to promote consensus and to validate further the ratings of necessity. In conclusion, necessity ratings can be used together with appropriateness ratings to address not only the overuse of procedures, but also to indicate limited access to care through underuse of procedures.

Angioplasty, Balloon, Coronary↗