Guideline adherence rates and interprofessional variation in a vignette study of depression.

OBJECTIVE: To assess the appropriateness of and variation in intention-to-treat decisions in the management of depression in the Netherlands. DESIGN: Mailed survey with 22 paper cases (vignettes) based on a population study. SETTING: A random sample from four professional groups in the Dutch mental healthcare system. SUBJECTS: 264 general practitioners, psychiatrists, psychotherapists, and clinical psychologists. MAIN OUTCOME MEASURES: Each vignette contained information on a number of patient characteristics taken from three national depression guidelines. The distribution of patient characteristics was based on data from a population study. Respondents were asked to choose the best treatment option and the best treatment setting. For each vignette we examined which of the selected treatments was appropriate according to the recommendations of the three published Dutch clinical guidelines and a panel of experts. RESULTS: 31% of all intention-to-treat decisions were not consistent with the guidelines. Overall, less severe depression, alcohol abuse, psychotic features, and lack of social resources were related to more inappropriate judgements. There was considerable variation between the professional groups: psychiatrists made more appropriate choices than the other professions although they had the highest rate of overtreatment. CONCLUSIONS: There is sufficient variation in the intentions to treat depression to give it priority in quality assessment and guideline development. Efforts to achieve appropriate care should focus on treatment indications, referral patterns, and overtreatment.

European criteria for the appropriateness and necessity of coronary revascularization procedures.

OBJECTIVES: Large variations in the use of coronary revascularization procedures have led many countries to apply the RAND appropriateness method to develop specific criteria describing patients who should be offered these procedures. The method is based on the work of a multidisciplinary expert panel that reviews a synthesis of the scientific evidence and rates the appropriateness of a comprehensive list of indications for the procedure being studied. Previous studies, however, have all involved single-country panels. We tested the feasibility of carrying out a multinational panel to rate the appropriateness and necessity of coronary revascularization, thereby producing recommendations for common European criteria. METHODS: Using the RAND methodology, a multispecialty (interventional cardiologists, non-interventional cardiologists and cardiovascular surgeons), multinational (The Netherlands, Spain, Sweden, Switzerland and the United Kingdom) panel rated the appropriateness and necessity of indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). A synthesis of the evidence and list of indications for PTCA and CABG were sent to 15 panelists, three from each country, who performed their ratings in three rounds. RESULTS: For PTCA, 24% of the indications were appropriate and necessary, 16% were appropriate, 43% were uncertain and 17% were inappropriate. The corresponding values for CABG were 33% appropriate and necessary, 7% appropriate, 40% uncertain and 20% inappropriate. The proportion of indications rated with disagreement was 4% for PTCA and 7% for CABG. CONCLUSION: Multinational panels appear to be a feasible method of addressing issues concerning the appropriateness and necessity of medical procedures in western European countries. The criteria produced provide a common tool that can be used to measure the overuse and underuse of medical procedures and to guide decision-making.