title: The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands.
abstract: 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.
  
  
  METHODS
  Prospective study of intention to treat decisions using a computerised expert system.
  
  
  METHODS
  "Presentation" sessions in 10 tertiary referral heart centres in 1992.
  
  
  METHODS
  3207 consecutive patients: 1618 CABG and 1589 PTCA candidates.
  
  
  METHODS
  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.
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
authors.forename: A P
authors.initials: AP
authors.lastname: Meijler
authors.forename: H
authors.initials: H
authors.lastname: Rigter
authors.forename: S J
authors.initials: SJ
authors.lastname: Bernstein
authors.forename: J K
authors.initials: JK
authors.lastname: Scholma
authors.forename: J
authors.initials: J
authors.lastname: McDonnell
authors.forename: A
authors.initials: A
authors.lastname: Breeman
authors.forename: J B
authors.initials: JB
authors.lastname: Kosecoff
authors.forename: R H
authors.initials: RH
authors.lastname: Brook
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D002983:Clinical Competence; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000473:pathology / Q000601:surgery / Q000628:therapy; D003331:Coronary Vessels / Q000473:pathology; D006801:Humans; D008875:Middle Aged; D009204:Myocardial Revascularization; D009426:Netherlands; D018579:Patient Selection; D011446:Prospective Studies