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Health Serv Res. 1989 Aug; 24(3): 351–407.
PMCID: PMC1065571

Unnecessary surgery.


The extent of unnecessary surgery has been the object of considerable speculation and occasional wild accusation in recent years. Most evidence of the existence of unnecessary surgery, such as information from studies of geographic variations and the results of second surgical opinion programs, is circumstantial. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations the fraction that are unwarranted could be as high as 30 percent. Most unnecessary surgery results from physician uncertainty about the effectiveness of an operation. Elimination of this uncertainty requires more efficient production and dissemination of scientific information about clinical effectiveness. In the absence of adequate data from scientific studies, the use of a consensus of expert opinion, disseminated by means of comprehensive practice guidelines, offers the best opportunity to identify and eliminate unnecessary surgery.

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  • Anderson GM, Lomas J. Determinants of the increasing cesarean birth rate. Ontario data 1979 to 1982. N Engl J Med. 1984 Oct 4;311(14):887–892. [PubMed]
  • Berwick DM, Coltin KL. Feedback reduces test use in a health maintenance organization. JAMA. 1986 Mar 21;255(11):1450–1454. [PubMed]
  • Bombardier C, Fuchs VR, Lillard LA, Warner KE. Socioeconomic factors affecting the utilization of surgical operations. N Engl J Med. 1977 Sep 29;297(13):699–705. [PubMed]
  • Bunker JP. Surgical manpower. A comparison of operations and surgeons in the United States and in England and Wales. N Engl J Med. 1970 Jan 15;282(3):135–144. [PubMed]
  • Bunker JP, Brown BW., Jr The physician-patient as an informed consumer of surgical services. N Engl J Med. 1974 May 9;290(19):1051–1055. [PubMed]
  • Cageorge SM, Roos LL, Jr, Danzinger R. Gallbladder operations: a population-based analysis. Med Care. 1981 May;19(5):510–525. [PubMed]
  • Chassin MR, Kosecoff J, Park RE, Winslow CM, Kahn KL, Merrick NJ, Keesey J, Fink A, Solomon DH, Brook RH. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987 Nov 13;258(18):2533–2537. [PubMed]
  • Chassin MR, Brook RH, Park RE, Keesey J, Fink A, Kosecoff J, Kahn K, Merrick N, Solomon DH. Variations in the use of medical and surgical services by the Medicare population. N Engl J Med. 1986 Jan 30;314(5):285–290. [PubMed]
  • Diehr P. Small area statistics: large statistical problems. Am J Public Health. 1984 Apr;74(4):313–314. [PMC free article] [PubMed]
  • DOYLE JC. Unnecessary hysterectomies: study of 6,248 operations in thirty-five hospitals during 1948. J Am Med Assoc. 1953 Jan 31;151(5):360–365. [PubMed]
  • Eddy DM. Variations in physician practice: the role of uncertainty. Health Aff (Millwood) 1984 Summer;3(2):74–89. [PubMed]
  • Eisenberg JM. An educational program to modify laboratory use by house staff. J Med Educ. 1977 Jul;52(7):578–581. [PubMed]
  • Eisenberg JM, Nicklin D. Use of diagnostic services by physicians in community practice. Med Care. 1981 Mar;19(3):297–309. [PubMed]
  • Elliott RV, Kahn KA, Kaye R. Physicians measure up. A study of 13 surgical procedures. JAMA. 1981 Feb 13;245(6):595–600. [PubMed]
  • Emerson R. Unjustified surgery. Fact or myth? N Y State J Med. 1976 Mar;76(3):454–460. [PubMed]
  • Gertman PM, Stackpole DA, Levenson DK, Manuel BM, Brennan RJ, Janko GM. Second opinions for elective surgery. The mandatory medicaid program in Massachusetts. N Engl J Med. 1980 May 22;302(21):1169–1174. [PubMed]
  • Grafe WR, McSherry CK, Finkel ML, McCarthy EG. The Elective Surgery Second Opinion Program. Ann Surg. 1978 Sep;188(3):323–330. [PMC free article] [PubMed]
  • Greenspan AM, Kay HR, Berger BC, Greenberg RM, Greenspon AJ, Gaughan MJ. Incidence of unwarranted implantation of permanent cardiac pacemakers in a large medical population. N Engl J Med. 1988 Jan 21;318(3):158–163. [PubMed]
  • Greer AL. The state of the art versus the state of the science. The diffusion of new medical technologies into practice. Int J Technol Assess Health Care. 1988;4(1):5–26. [PubMed]
  • Griner PF. Use of laboratory tests in a teaching hospital: long-term trends: reductions in use and relative cost. Ann Intern Med. 1979 Feb;90(2):243–248. [PubMed]
  • Hulka BS, Wheat JR. Patterns of utilization. The patient perspective. Med Care. 1985 May;23(5):438–460. [PubMed]
  • Joffe J. Evaluating a voluntary second surgical opinion program. Eval Health Prof. 1980 Dec;3(4):421–433. [PubMed]
  • LEMBCKE PA. Measuring the quality of medical care through vital statistics based on hospital service areas; I. Comparative study of appendectomy rates. Am J Public Health Nations Health. 1952 Mar;42(3):276–286. [PMC free article] [PubMed]
  • Lewis CE. Variations in the incidence of surgery. N Engl J Med. 1969 Oct 16;281(16):880–884. [PubMed]
  • LoGerfo JP, Efird RA, Diehr PK, Richardson WC. Rates of surgical care in prepaid group practices and the independent setting: what are the reasons for the differences? Med Care. 1979 Jan;17(1):1–10. [PubMed]
  • Manning WG, Leibowitz A, Goldberg GA, Rogers WH, Newhouse JP. A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med. 1984 Jun 7;310(23):1505–1510. [PubMed]
  • Martin SG, Shwartz M, Whalen BJ, D'Arpa D, Ljung GM, Thorne JH, McKusick AE. Impact of a mandatory second-opinion program on medicaid surgery rates. Med Care. 1982 Jan;20(1):21–45. [PubMed]
  • McCarthy EG, Widmer GW. Effects of screening by consultants on recommended elective surgical procedures. N Engl J Med. 1974 Dec 19;291(25):1331–1335. [PubMed]
  • McCarthy EG, Finkel ML. Second opinion elective surgery programs: outcome status over time. Med Care. 1978 Dec;16(12):984–994. [PubMed]
  • McCarthy EG, Finkel ML. Surgical utilization in the U.S.A. Med Care. 1980 Sep;18(9):883–892. [PubMed]
  • McCarthy EG, Finkel ML, Ruchlin HS. Second opinions on elective surgery. The Cornell/New York Hospital study. Lancet. 1981 Jun 20;1(8234):1352–1354. [PubMed]
  • McNeil BJ, Pauker SG, Sox HC, Jr, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med. 1982 May 27;306(21):1259–1262. [PubMed]
  • McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982 Nov 18;307(21):1310–1314. [PubMed]
  • Merrick NJ, Brook RH, Fink A, Solomon DH. Use of carotid endarterectomy in five California Veterans Administration medical centers. JAMA. 1986 Nov 14;256(18):2531–2535. [PubMed]
  • Park RE, Fink A, Brook RH, Chassin MR, Kahn KL, Merrick NJ, Kosecoff J, Solomon DH. Physician ratings of appropriate indications for six medical and surgical procedures. Am J Public Health. 1986 Jul;76(7):766–772. [PMC free article] [PubMed]
  • Pauly MV. What is unnecessary surgery? Milbank Mem Fund Q Health Soc. 1979 Winter;57(1):95–117. [PubMed]
  • Payne SM. Identifying and managing inappropriate hospital utilization: a policy synthesis. Health Serv Res. 1987 Dec;22(5):709–769. [PMC free article] [PubMed]
  • Perkoff GT, Ballinger WF, Turner JK, Kahn L. Lack of effect of an experimental prepaid group practice on utilization of surgical care. Surgery. 1975 May;77(5):619–623. [PubMed]
  • Roos NP. Hysterectomy: variations in rates across small areas and across physicians' practices. Am J Public Health. 1984 Apr;74(4):327–335. [PMC free article] [PubMed]
  • Roos NP, Roos LL. High and low surgical rates: risk factors for area residents. Am J Public Health. 1981 Jun;71(6):591–600. [PMC free article] [PubMed]
  • Roos NP, Roos LL., Jr Surgical rate variations: do they reflect the health or socioeconomic characteristics of the population? Med Care. 1982 Sep;20(9):945–958. [PubMed]
  • Roos NP, Roos LL, Jr, Henteleff PD. Elective surgical rates--do high rates mean lower standards? Tonsillectomy and adenoidectomy in Manitoba. N Engl J Med. 1977 Aug 18;297(7):360–365. [PubMed]
  • Roper WL, Winkenwerder W, Hackbarth GM, Krakauer H. Effectiveness in health care. An initiative to evaluate and improve medical practice. N Engl J Med. 1988 Nov 3;319(18):1197–1202. [PubMed]
  • Ruchlin HS, Finkel ML, McCarthy EG. The efficacy of second-opinion consultation programs: a cost-benefit perspective. Med Care. 1982 Jan;20(1):3–20. [PubMed]
  • Stockwell H, Vayda E. Variations in surgery in Ontario. Med Care. 1979 Apr;17(4):390–396. [PubMed]
  • Vayda E. A comparison of surgical rates in Canada and in England and Wales. N Engl J Med. 1973 Dec 6;289(23):1224–1229. [PubMed]
  • Vayda E, Barnsley JM, Mindell WR, Cardillo B. Five-year study of surgical rates in Ontario's counties. Can Med Assoc J. 1984 Jul 15;131(2):111–115. [PMC free article] [PubMed]
  • Vayda E, Mindell WR, Mueller CB, Yaffe B. Measuring surgical decision-making with hypothetical cases. Can Med Assoc J. 1982 Aug 15;127(4):287–290. [PMC free article] [PubMed]
  • Ware JE, Jr, Brook RH, Rogers WH, Keeler EB, Davies AR, Sherbourne CD, Goldberg GA, Camp P, Newhouse JP. Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care. Lancet. 1986 May 3;1(8488):1017–1022. [PubMed]
  • Wennberg JE. Dealing with medical practice variations: a proposal for action. Health Aff (Millwood) 1984 Summer;3(2):6–32. [PubMed]
  • Wennberg JE, Gittelsohn A. Health care delivery in Maine I: patterns of use of common surgical procedures. J Maine Med Assoc. 1975 May;66(5):123–149. [PubMed]
  • Wennberg JE, Fowler FJ., Jr A test of consumer contribution to small area variations in health care delivery. J Maine Med Assoc. 1977 Aug;68(8):275–279. [PubMed]
  • Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med. 1982;16(7):811–824. [PubMed]
  • Winslow CM, Kosecoff JB, Chassin M, Kanouse DE, Brook RH. The appropriateness of performing coronary artery bypass surgery. JAMA. 1988 Jul 22;260(4):505–509. [PubMed]

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