The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands.

Abstract

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.

Underuse of Coronary Revascularization Procedures in Patients Considered Appropriate Candidates for Revascularization

“…Expert panels' ratings of the appropriateness of revascularization in patients with a variety of typical indications, determined according to the RAND-University of California at Los Angeles (UCLA) method, make this judgment explicit, by making it possible to assign patients a score on a scale that ranges from appropriate through uncertain to inappropriate. Studies using this method have shown that overuse [2][3][4][5][6][7][8][9][10][11] of invasive techniques in the management of coronary disease is uncommon, and attention has turned to the issue of underuse. [12][13][14][15][16] Well-designed expert panels can closely reflect the views of practicing physicians, 17 and methods for detecting the underuse of revascularization are highly reproducible.…”

Waiting for coronary revascularization: A comparison between New York State, the Netherlands and Sweden

“…For bypass surgery, where the risk of adverse events on the waiting list is greatest, the inappropriate rate ranged from 2% in New York State to 8% in Sweden, with 5% of cases inappropriate in the Netherlands. The appropriateness of PTCA was more questionable with about 40% of cases at each site judged uncertain in appropriateness [14,15] (Swedish Council on Technology Assessment in Health Care, unpublished data).…”

“…Data were reviewed for completeness and accuracy before being entered into the computerized data base. Additional details regarding the way cases were selected, data collected and confidentiality maintained are described elsewhere [13][14][15].…”

“…In the Netherlands, we prospectively collected data on patients referred for consideration of coronary revascularization to 10 of the 13 heart centers in the Netherlands [14]. Enrollment in the study began between February and September 1992, depending on the center, with the goal of enrolling a consecutive sample of patients from each center.…”

“…These data were originally collected to assess the appropriateness of use of PTCA and CABG at each of these sites [13][14][15][16]. In order to assure that differences in waiting time reflected differences in styles of practice (e.g., urgency of the procedure) and not differences in the type of patients undergoing the procedure (e.g., the proportion of patients presenting with unstable angina vs. chronic stable angina vs. acute myocardial infarction) we restricted these analyses to one group of patients present in all three datasets, chronic stable angina patients who had not previously undergone bypass surgery.…”