[The appropriateness of diagnostic angiography in cardiology].
Coronary angiography is the most frequently performed invasive diagnostic test in the western world, but regional differences are common and have been outlined in both observational and randomized studies. Appropriateness evaluation is hence fundamental, as the use of invasive cardiac procedures is strongly associated with the population-based availability of catheterization facilities. A procedure is judged appropriate if the expected health benefit exceeds the possible negative consequences by a sufficiently wide margin; it is necessary when not performing it could result in harm for the patient. In the first period (1980-1995) researchers seemed to try to find an explanation for geographic variations regarding overuse: the appropriateness remained at the same level through time (75%), while a trend towards a reduction in the number of inappropriate procedures (< or = 20%) and an increase in that of the uncertain ones was evident. The different opinions of the expert panels constituted the major cause of variability. The factors mainly affecting the appropriateness were advanced age, angina class, intensity of medical therapy, exercise test results and income. Canadians and Europeans seemed to request a higher standard of scientific evidence as compared to US doctors; surgeons tended to give higher scores than cardiologists and internists. Inappropriate indications were similar in high- and low-use hospitals. More recently, important data emerged on the lower than necessary use of this procedure and this was more evident in hospitals without on-site catheterization facilities and in patients without fee-for-service insurance. Patient selection was suboptimal and coronary angiography was more frequently performed in low-risk populations. This phenomenon is of concern, because the lower than necessary use of indicated procedures can bear on the patients' outcome. In fact, an inverse relationship between mortality and coronary angiography use has been observed, especially in patients in whom it has been judged necessary. No lower than necessary use of differences in appropriateness have been found in females, but this is possible in ethnic minorities. If the appropriateness is to be improved, specific actions have to be directed to increase the know-how of doctors, patients, and administrators, to promote research in the fields where knowledge is still missing and to implement simplified guidelines and appropriateness criteria, in order to favor a more extensive use. It is mandatory to assess the necessity of coronary angiography procedures and to grant access to those patients who meet the necessity criteria.
Dipartimento di Scienze Cardiovascolari U.O. di Cardiologia Azienda Ospedaliera S. Maria della Misericordia Piazzale S. Maria della Misericordia, 15, 33100 Udine. guglbern@tin.it
Guglielmo
G
Bernardi
Giorgio
G
Morocutti
Leonardo
L
Spedicato
Valentino
V
Moretti
Duilio
D
Tuniz
Paolo Maria
PM
Fioretti
D002170:Canada; D017023:Coronary Angiography / Q000592:standards* / Q000706:statistics & numerical data; D003327:Coronary Disease / Q000000981:diagnostic imaging*; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008913:Minority Groups / Q000706:statistics & numerical data; D018579:Patient Selection; D011379:Prognosis; D011785:Quality Assurance, Health Care; D017678:Sex Distribution; D014481:United States