Criteria for the appropriate use of percutaneous transluminal coronary angioplasty and coronary artery bypass surgery

Introduction and objectives. The large differences in rates of use of clinical procedures among regions, hospitals and physicians raise questions as to whether some population groups are receiving inappropriate procedures or others are not receiving necessary ones. The objective of this study is to develop criteria for the appropriate use of coronary revascularization procedures in Spain. Methods. Following the RAND appropriateness method, criteria were developed for the appropriate use of coronary revascularization (percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery) in Spain. A literature review was produced as well as a comprehensive and mutually exclusive list of 1,826 indications for coronary revascularization. A panel of 12 experts (4 interventional cardiologists, 4 non-interventional cardiologists and 4 cardiovascular surgeons) rated the appropriateness of each indication on a scale from 1 (highly inappropriate) to 9 (highly appropriate). The ratings were made twice; anonymously in the first round, and during a 2-day meeting in the second round. In accordance with the panellists' mean rating and level of agreement, each indication was classified as appropriate, uncertain or inappropriate for revascularization, angioplasty and bypass surgery. Results. Criteria have been developed for the appropriate use of angioplasty and bypass surgery which can be applied to patients with coronary artery disease. The combination of clinicial characteristics makes it possible to classify patients with a high degree of specificity. Conclusions. These criteria can be used retrospectively, to measure the proportions of appropriate use, or prospectively, as an aid to decision making in order to promote the appropriate use of coronary revascularization.