Assessing the appropriateness of coronary revascularization: The university of maryland revascularization appropriateness score (ras) and its comparison to rand expert panel ratings and american college of cardiology/american heart association guidelines with regard to assigned appropriateness rating and ability to predict outcome

Abstract

Background:Significant regional variation in procedural frequencies has led to the development of the RAND and American College of Cardiology/American Heart Association (ACC/AHA) guidelines; however, they may be difficult to apply in clinical practice. The University of Maryland Revascularization Appropriateness Score (RAS) was created to address the need for a simplified point scoring system. Hypothesis:The study was undertaken to compare revascularization appropriateness ratings yielded by the RAND Expert Panel Ratings, ACC/AHA guidelines, and the University of Maryland RAS. Methods:We applied these three revascularization appropriateness scoring systems to 153 catheterization laboratory patients with a variety of cardiac diagnoses and treatments. For each patient, appropriateness scores assigned by each of the three systems were compared with each other and with the actual treatment delivered. Concordance of care with appropriateness score was then correlated with outcome. Results:There were significant differences among all three scoring systems in their ratings and in the concordance of treatment with appropriateness rating. When treatment provided was concordant with RAND rating, there was a lower occurrence of subsequent coronary artery bypass grafting (CABG), the composite end point of either CABG or percutaneous transluminal coronary angioplasty (PTCA), and the composite end point of death, myocardial infarction (MI), or revascularization. When treatment was concordant with the ACC/AHA guidelines, there was lower occurrence of all‐cause mortality, PTCA, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. When treatment provided was concordant with the RAS, there was lower occurrence of cardiac death, all‐cause death, CABG, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. Conclusions:The RAS is a simple scoring system to assess revascularization appropriateness. When the RAND, ACC/AHA, and RAS systems are compared in a catheterization laboratory population, they rate the same patient differently and vary in their correlation of appropriateness rating with outcome.

The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures

“…Furthermore, the study authors described a graded relationship between rating and outcome over the entire scale of appropriateness (linear trend P 5 0.002) [33]. We did identify one study that found no association between concordant vs. discordant care and mortality; however, this study had a smaller sample size than the other three (153 patients vs. 2,552e5,026 patients) [23].…”

“…The European studies focused on upper gastrointestinal (GI) endoscopy [18,19] or colonoscopy [24], whereas the US studies looked at CABG [20,21,23], hysterectomy [22], and upper GI endoscopy [26]. Construct validity has also been studied by comparing RAND/UCLA appropriateness method ratings with published evidence from trials and observational studies.…”

“…Of the included articles, 5 assessed reliability, 21 assessed validity, and 17 assessed the effect of altering panel composition or eliminating the in-person discussion between rating rounds. Specifically, the testeretest reliability was reported by four articles [13e16], interpanel reliability by one article [17], comparison with guideline recommendations by nine articles [18e26], comparison with published evidence by three articles [16,27,28], comparison with a form of decision analysis by four articles [29e32], and predictive validity by four articles [20,23,33,34]. We identified one article that reported the concordance between RAND/UCLA appropriateness method panel results and subsequent randomized controlled trial results [35].…”

An examination of factors influencing the choice of therapy for patients with coronary artery disease

“…A range of studies have reported that a not insignificant proportion of PTCAs and, to a lesser degree, CABGs are performed inappropriately or with uncertain appropriateness [9-11]. These figures vary according to location (e.g.…”