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.

The appropriateness of performing coronary artery bypass surgery.

Information about how appropriately procedures are performed is vital to the understanding of the impact of technology and to the success of efforts to channel its use appropriately. While the efficacy of coronary artery bypass surgery has been addressed in several large-scale, randomized trials, there is little information about how appropriately the procedure is actually being used in the community. We determined the appropriateness of coronary artery bypass surgeries performed in three randomly chosen hospitals in a western state. We determined appropriateness by comparing data obtained from a detailed medical record review with a list of 488 indications. This list, developed by a national panel of physicians, covered all possible reasons for performing the procedure. Three hundred eighty-six cases from the years 1979, 1980, and 1982 were examined. Fifty-six percent of the surgeries were performed for appropriate reasons, 30% for equivocal reasons, and 14% for inappropriate reasons. The percentage of appropriate surgeries varied by hospital, from 37% to 78%, but did not vary by patient age. Eliminating the performance of inappropriate procedures may lead to reductions in health care expenditures or to improved patient outcomes.

Diagnosis and treatment of coronary disease: comparison of doctors' attitudes in the USA and the UK.

Two panels of doctors, one in the USA and one in the UK, were asked to indicate how appropriate they judged a series of possible indications for coronary angiography and coronary artery bypass graft (CABG) operations. "Appropriateness" was defined with respect to possible benefit to the patient and excluded considerations of cost. The indications were presented as a series of detailed clinical situations in which the procedure might be used, and for each indication individual panel members rated appropriateness on a scale of 1 to 9. The US panel judged more indications appropriate than did the UK panel, and there was more agreement among the members of the US panel than among those of the UK panel. Although the two panels tended to rate the appropriateness of the indications in the same order, the UK panel placed more emphasis than did the US panel on the importance of symptoms and the amount of medical treatment. Application of the panels' ratings to two groups of patients who had had coronary angiography showed that 17% and 27% of the investigations had been inappropriate by the standards of the US panel, whereas 42% and 60% were inappropriate by the UK panel ratings. 13% of the CABG operations studied were inappropriate by the US and 35% by the UK panel ratings.