Rating the appropriateness of coronary angiography, coronary angioplasty and coronary artery bypass grafting: the ACRE study. Appropriateness of Coronary Revascularisation study.
BACKGROUND
Previous studies investigating the appropriateness of invasive management of coronary disease had not reported the internal consistency of their ratings and may now be out of date. The aim of this study was to measure the influence of clinical factors on contemporary ratings of the appropriateness of coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Appropriateness of Coronary Revascularisation (ACRE) study.


METHODS
The Delphi-RAND technique was used, in which an expert panel (four cardiologists, three cardiothoracic surgeons, a general physician and a general practitioner), meeting in 1995, rated mutually exclusive indications (n = 2178 for angiography, n = 995 for PTCA and n = 984 for CABG). The main outcome measures were the appropriateness category (inappropriate, uncertain or appropriate) for each of the three procedures and treatment preference.


RESULTS
For revascularization, the strongest determinant of inappropriateness was coronary anatomy. The odds ratio (OR) for inappropriate PTCA was 10.6 (95 per cent confidence interval (CI) 4.8-23.5) for the effect of left main stem or three-vessel disease versus single-vessel disease, and for CABG it was 0.06 (95 per cent CI 0.03-0.15). The number of diseased vessels was strongly related to preference for medical, PTCA or CABG treatment (p for linear trend <0.001). Mild versus severe anginal symptoms were associated with inappropriate angiography (OR 2.0 (95 per cent CI 0.9-9.8), although this effect was stronger when only the cardiologists' ratings were considered (OR 10.1 (95 per cent CI 2.4-42.6)).


CONCLUSIONS
These are the first UK ratings of appropriateness covering all three procedures. The associations with clinical factors provide evidence of the internal consistency of these ratings. Prospective validation of these ratings against clinical outcomes is under way in the ACRE study.
Hemingway
H
H
Department of Research and Development, Kensington & Chelsea and Westminster Health Authority, London.
Crook
A M
AM
Dawson
J R
JR
Edelman
J
J
Edmondson
S
S
Feder
G
G
Kopelman
P
P
Leatham
E
E
Magee
P
P
Parsons
L
L
Timmis
A D
AD
Wood
A
A
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data*; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data*; D003657:Decision Making; D003697:Delphi Technique; D006300:Health Services Misuse / Q000706:statistics & numerical data; D006331:Heart Diseases / Q000145:classification / Q000601:surgery; D006801:Humans; D011787:Quality of Health Care; D013222:State Medicine; D016896:Treatment Outcome; D006113:United Kingdom; D019564:Unnecessary Procedures / Q000706:statistics & numerical data; D014600:Utilization Review / Q000145:classification* / Q000706:statistics & numerical data