Validity of Criteria Used for Detecting Underuse of Coronary Revascularization

Kravitz, Richard L.; Laouri, Marianne; Kahan, James P.; Guzy, Peter M.; Sherman, Todd; Hilborne, Lee H.; Brook, Robert H.

doi:10.1001/jama.1995.03530080048040

Cited by 143 publications

(72 citation statements)

References 10 publications

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“…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. 18 Despite reports on the ratings of a large number of expert panels 2-11 on coronary revascularization, a central aspect of the validity of the appropriateness-rating method remains untested.…”

Section: Resultsmentioning

confidence: 99%

“…It is common for patients not to receive appropriate invasive treatment for coronary disease; 22 to 41 percent of patients for whom expert panels deem a procedure not only appropriate but also necessary do not undergo the procedure. [12][13][14][15][16] The only previous study of clinical outcomes 12 found retrospectively that, among patients for whom revascularization was deemed necessary, the rate of survival was higher and there was less chest pain among those who underwent revascularization than among those who were treated medically. However, the study was limited by insufficient statistical power to separate outcomes in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) from those in patients undergoing coronary-artery bypass grafting (CABG).…”

Section: Resultsmentioning

confidence: 99%

“…[12][13][14][15][16] As in other studies of appropriateness, matching data abstracted from clinical records with hypothetical clinical indications creates a potential source of bias. Neither the predefined indication nor the clinical record may adequately characterize the patient.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2001

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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

et al. 2001

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“…58 Other data are likewise supportive. 59 Similar tests of external validity of other consensus methods are less often reported.…”

Section: Consensus Methodsmentioning

confidence: 99%

Are there roles for observational database studies and structured quantification of expert opinion to answer therapy controversies in transplants?

Gale

Eapen

Logan

et al. 2009

Bone Marrow Transplant

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Approaches to determine whether one transplant-related therapy is better than another include: (1) using experimental data, such as those from randomized controlled trials (RCTs); (2) using observational data, such as those from observational databases (ODBs) and (3) using conclusions from the structured quantification of expert opinion based on a consideration of evidence from RCTs, ODBs and other sources. Large RCTs are widely and appropriately regarded as the gold standard of clinical investigation. However, data from large RCTs are rarely available for transplant-related therapy questions. We discuss some of the limitations of RCTs in the transplant setting often including small size and short follow-up. These limitations are only partly solved by meta-analyses of RCTs. Data from high-quality ODBs are not only often useful in this setting but also have limitations. Biases may be difficult or impossible to identify and/or adjust for. However, ODBs have large numbers of diverse subjects receiving diverse therapies and analyses that often give answers more useful to clinicians than RCTs. Side-by-side comparisons suggest analyses from high-quality ODBs often give similar conclusions to meta-analyses of highquality RCTs. Meta-analyses combining data from RCTs and ODBs are sometimes appropriate. Quantitation of expert opinion, when of high quality, is also useful: experts rarely disagree under precisely defined circumstances and their consensus conclusions are often concordant with results of high-quality RCTs and ODBs. We suggest increased use of ODBs and expert opinion as reliable and effective ways to determine relative efficacies of new therapies in transplant settings.

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“…Those receiving a revascularization procedure deemed necessary (concordant therapy) had a lower mortality and less chest pain at 2 years post procedure than those in whom revascularization was deemed necessary but who were treated with medical therapy (discordant therapy). 21 We therefore investigated clinical outcome in this selected population of catheterization laboratory patients to determine whether treatment that was concordant with the ratings of RAND, ACC/AHA, and RAS correlated with improved outcome and further to identify which clinical outcomes were best predicted by each system.…”

Section: Introductionmentioning

confidence: 99%

Assessing the appropriateness of coronary revascularization: The university of maryland revascularization appropriateness score (ras) and its comparison to rand expert panel ratings and american college of cardiology/american heart association guidelines with regard to assigned appropriateness rating and ability to predict outcome

Ziskind

Lauer

Bishop

et al. 1999

Clinical Cardiology

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Background:Significant regional variation in procedural frequencies has led to the development of the RAND and American College of Cardiology/American Heart Association (ACC/AHA) guidelines; however, they may be difficult to apply in clinical practice. The University of Maryland Revascularization Appropriateness Score (RAS) was created to address the need for a simplified point scoring system. Hypothesis:The study was undertaken to compare revascularization appropriateness ratings yielded by the RAND Expert Panel Ratings, ACC/AHA guidelines, and the University of Maryland RAS. Methods:We applied these three revascularization appropriateness scoring systems to 153 catheterization laboratory patients with a variety of cardiac diagnoses and treatments. For each patient, appropriateness scores assigned by each of the three systems were compared with each other and with the actual treatment delivered. Concordance of care with appropriateness score was then correlated with outcome. Results:There were significant differences among all three scoring systems in their ratings and in the concordance of treatment with appropriateness rating. When treatment provided was concordant with RAND rating, there was a lower occurrence of subsequent coronary artery bypass grafting (CABG), the composite end point of either CABG or percutaneous transluminal coronary angioplasty (PTCA), and the composite end point of death, myocardial infarction (MI), or revascularization. When treatment was concordant with the ACC/AHA guidelines, there was lower occurrence of all‐cause mortality, PTCA, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. When treatment provided was concordant with the RAS, there was lower occurrence of cardiac death, all‐cause death, CABG, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. Conclusions:The RAS is a simple scoring system to assess revascularization appropriateness. When the RAND, ACC/AHA, and RAS systems are compared in a catheterization laboratory population, they rate the same patient differently and vary in their correlation of appropriateness rating with outcome.

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Validity of Criteria Used for Detecting Underuse of Coronary Revascularization

Cited by 143 publications

References 10 publications

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

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

Are there roles for observational database studies and structured quantification of expert opinion to answer therapy controversies in transplants?

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