title: Association between publication of appropriate use criteria and the temporal trends in diagnostic angiography in stable coronary artery disease: A population-based study.
abstract: The appropriate use criteria (AUC) were developed to aid clinicians in making clinical decisions regarding coronary angiography. The aim of the present study was to evaluate the association between the publication of the AUC criteria in diagnostic angiography and rates of angiography in Ontario.
  
  
  
  Our cohort consisted of all patients who underwent coronary angiography in Ontario from 1st October 2008 to 31st October 2013 for the indication of suspected stable coronary artery disease. We determined monthly age- and sex-standardized rates of angiography per 100,000 adults. To determine the association between the publication of the AUC for diagnostic angiograms and the rates of angiography, we conducted a time series analysis using an autoregressive integrated moving average model. As a sensitivity analyses, we evaluated the impact of the AUC on the rates of percutaneous coronary intervention (PCI) per 100 angiograms.
  
  
  
  We included 114,551 angiograms for stable coronary artery disease. In the period prior to the publication of the AUC, the average monthly age- and sex-standardized rate of angiography was 18.7 per 100,000; post-AUC, the average monthly rate decreased to 17.6 per 100,000 adults (P = .037). In contrast, in the 29,358 PCIs included in the analysis, the monthly PCI rates per 100 angiograms were unchanged (25.2 pre-AUC; 26.8 post-AUC; P = .29). In the sensitivity analysis, the rate of appropriate/inappropriate and uncertain indication did not significantly change over the study period.
  
  
  
  The publication of the diagnostic angiography AUC criteria was associated with a decrease in the population rates of diagnostic angiography. This suggests that the AUC potentially was associated with an increased threshold to pursue invasive diagnostic testing.
authors.affiliation: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada; University of Toronto, Ontario, Canada.
authors.forename: Yaron
authors.initials: Y
authors.lastname: Arbel
authors.affiliation: Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada.
authors.forename: Feng
authors.initials: F
authors.lastname: Qiu
authors.affiliation: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Bennell
authors.affiliation: University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.affiliation: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada; University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
authors.forename: Idan
authors.initials: I
authors.lastname: Roifman
authors.affiliation: Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada.
authors.forename: Mohammad R
authors.initials: MR
authors.lastname: Rezai
authors.affiliation: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada; University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
authors.forename: Jack V
authors.initials: JV
authors.lastname: Tu
authors.affiliation: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada; University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.
authors.forename: Dennis T
authors.initials: DT
authors.lastname: Ko
authors.affiliation: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada; University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada. Electronic address: Harindra.Wijeysundera@sunnybrook.ca.
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
mesh_terms: D000368:Aged; D000066491:Clinical Decision-Making; D015331:Cohort Studies; D017023:Coronary Angiography / Q000379:methods / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000175:diagnosis*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D018579:Patient Selection