title: Variations in clinical decision-making between cardiologists and cardiac surgeons; a case for management by multidisciplinary teams?
abstract: OBJECTIVE
  To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons
  
  
  METHODS
  Six cases of coronary heart disease were presented at an open meeting in a standard format including clinical details which might influence the decision to revascularise. Clinicians (n = 53) were then asked to vote using an anonymous electronic system for one of 5 treatment options: medical, surgical (CABG), percutaneous coronary intervention (PCI) or initially medical proceeding to revascularisation if symptoms dictated. Each case was then discussed in an open forum following which clinicians were asked to revote. Differences in treatment preference were compared by chi squared test and agreement between groups and between voting rounds compared using Kappa.
  
  
  RESULTS
  Surgeons were more likely to choose surgery as a form of treatment (p = 0.034) while interventional cardiologists were more likely to choose PCI (p = 0.056). There were no significant differences between non-interventional and interventional cardiologists (p = 0.13) in their choice of treatment. There was poor agreement between all clinicians in the first round of voting (Kappa 0.26) but this improved to a moderate level of agreement after open discussion for the second vote (Kappa 0.44). The level of agreement among surgeons (0.15) was less than that for cardiologists (0.34) in Round 1, but was similar in Round 2 (0.45 and 0.45 respectively).
  
  
  CONCLUSIONS
  In this case series, there was poor agreement between cardiac clinical specialists in the choice of treatment offered to patients. Open discussion appeared to improve agreement. These results would support the need for decisions to revascularise to be made by a multidisciplinary panel.
authors.affiliation: Department of Cardiology, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK. mdenvir@staffmail.ed.ac.uk
authors.forename: M A
authors.initials: MA
authors.lastname: Denvir
authors.forename: J P
authors.initials: JP
authors.lastname: Pell
authors.forename: A J
authors.initials: AJ
authors.lastname: Lee
authors.forename: J
authors.initials: J
authors.lastname: Rysdale
authors.forename: R J
authors.initials: RJ
authors.lastname: Prescott
authors.forename: H
authors.initials: H
authors.lastname: Eteiba
authors.forename: A
authors.initials: A
authors.lastname: Walker
authors.forename: P
authors.initials: P
authors.lastname: Mankad
authors.forename: I R
authors.initials: IR
authors.lastname: Starkey
mesh_terms: D002309:Cardiology / Q000379:methods*; D003324:Coronary Artery Disease / Q000601:surgery*; D003657:Decision Making; D006801:Humans; D033183:Interdisciplinary Communication; D009204:Myocardial Revascularization / Q000379:methods*; D010348:Patient Care Team / Q000458:organization & administration*; D010818:Practice Patterns, Physicians'; D013903:Thoracic Surgery / Q000379:methods*