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Objective: To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons Design: 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) Conclusion: 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.

This study aimed to determine whether the changes in practice in the management of asthma since the early 1980s have improved standards (as assessed by higher actual/best function) and reduced the need for oral corticosteroids. All asthmatic outpatients were reviewed in 1980, 1983, 1988/89 and 1993/94. Therapeutic step, defined by suppressive medication alone, actual and best peak expiratory flow (PEF) were recorded. Cohorts from 1980, 1983 and 1988/89 were identified in whom best function was established on all subsequent occasions. Changes in practice demonstrated by cross-sectional review of all subjects were interpreted with the aid of longitudinal analysis of the cohorts. Attendance increased from 463 in 1980 to 772 in 1993/94. Between 1983 and 1993/94, the proportion maintained on inhaled corticosteroids increased from 49 to 84% with increased use of higher doses. Mean actual/best PEF rose from 80 to 87%, improving at each therapeutic step. The proportion needing rescue oral corticosteroids fell from 47 to 35% and maintenance oral corticosteroids from 20 to 9%. In the cohorts, there was a similar reduction in use of rescue corticosteroids, but not of maintenance oral corticosteroids. The study confirmed an increase in the use and dose of inhaled corticosteroids, and a better outcome at all treatment steps. The fall in the proportion of subjects dependent on oral corticosteroids was due to attrition, rather than weaning in later years.