Where information about the appropriateness of a surgical procedure is lacking, expert panels have been used to establish guidelines for medical practitioners. Such a panel was convened to assess the appropriateness of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery in the Netherlands. The panel, consisting of interventional cardiologists and cardiothoracic surgeons, used a modified Delphi process to rate 1126 clinical indications over two rounds. This article describes the degree of change in both agreement amongst members and in the appropriateness ratings over the two rounds, and examines the internal consistency of the ratings of individual panellists. Over the two rounds, agreement increased. Although most appropriateness ratings remained unchanged, there was significant movement from equivocal ratings to determinate ratings. While individual members showed some degree of inconsistency in their scoring, the panel as a whole scored very consistently. The observed changes in appropriateness were consistent with expectations, showing that the appropriateness method is used logically and consistently by panellists.

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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. Design-Prospective study of intention to treat decisions using a computerised expert system. Setting-"Presentation" sessions in 10 tertiary referral heart centres in 1992.

Objecti6e: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. Methods: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n=1486). We measured the median waiting time between coronary angiography and PTCA or CABG. New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P B0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (PB 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. Conclusions: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved. © 1997 Elsevier Science Ireland Ltd.

Although the level of agreement between expert panels and decision analysis on when a procedure is appropriate or effective may vary by procedure and the strength of the scientific evidence, we found that Dutch physicians agree much more strongly with decision analysis than U.S. physicians.