Appropriateness of referral of coronary angiography patients in Sweden

Abstract

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.

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

“…The prevalence of this syndrome is not well established, but data from registries suggest that about 10% of patients referred for angiography for symptomatic SIHD have coronary anatomy that is not amenable to revascularization. [933][934][935] Other nonpharmacological therapies may be considered in these patients in an effort to improve quality of life.…”

Underuse of Coronary Revascularization Procedures in Patients Considered Appropriate Candidates for Revascularization

“…Expert panels' ratings of the appropriateness of revascularization in patients with a variety of typical indications, determined according to the RAND-University of California at Los Angeles (UCLA) method, make this judgment explicit, by making it possible to assign patients a score on a scale that ranges from appropriate through uncertain to inappropriate. Studies using this method have shown that overuse [2][3][4][5][6][7][8][9][10][11] of invasive techniques in the management of coronary disease is uncommon, and attention has turned to the issue of underuse. [12][13][14][15][16] Well-designed expert panels can closely reflect the views of practicing physicians, 17 and methods for detecting the underuse of revascularization are highly reproducible.…”

Appropriateness of referrals for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a developing community: A comparison between 2005 and 2009 versions of ACCF/ASNC appropriateness criteria

“…In this regard, special attention has been paid to cardiovascular diagnostic procedures due to their clinical importance and high costs. Numerous studies are available that evaluate the contributing factors in physicians' decisions to refer a patient for cardiac catheterization [9][10][11][12] or cardiac computed tomography. 13 The number of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) performed annually has increased in many countries.…”