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Eur J Cardiothorac Surg 2000;18:380-387
© 2000 Elsevier Science NL

European criteria for the appropriateness and necessity of coronary revascularization procedures

^a Health Services Research Unit, Carlos III Health Institute, Madrid, Spain
^b RAND Europe, Leiden, The Netherlands
^c Department of Medicine, University of Michigan, Ann Arbor, MI, USA
^d Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA

Received 18 February 2000; received in revised form 31 May 2000; accepted 28 June 2000.

Corresponding author. Unidad de Investigación en Servicios de Salud (UISS), Subdirección General de Epidemiología e Información Sanitaria, Instituto de Salud Carlos III, Calle Sinesio Delgado 6, 28029 Madrid, Spain. Tel.: +34-91-387-7803 extn. 2010; fax: +34-91-387-7896
e-mail: kfitch{at}isciii.es

Objectives: Large variations in the use of coronary revascularization procedures have led many countries to apply the RAND appropriateness method to develop specific criteria describing patients who should be offered these procedures. The method is based on the work of a multidisciplinary expert panel that reviews a synthesis of the scientific evidence and rates the appropriateness of a comprehensive list of indications for the procedure being studied. Previous studies, however, have all involved single-country panels. We tested the feasibility of carrying out a multinational panel to rate the appropriateness and necessity of coronary revascularization, thereby producing recommendations for common European criteria. Methods: Using the RAND methodology, a multispecialty (interventional cardiologists, non-interventional cardiologists and cardiovascular surgeons), multinational (The Netherlands, Spain, Sweden, Switzerland and the United Kingdom) panel rated the appropriateness and necessity of indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). A synthesis of the evidence and list of indications for PTCA and CABG were sent to 15 panelists, three from each country, who performed their ratings in three rounds. Results: For PTCA, 24% of the indications were appropriate and necessary, 16% were appropriate, 43% were uncertain and 17% were inappropriate. The corresponding values for CABG were 33% appropriate and necessary, 7% appropriate, 40% uncertain and 20% inappropriate. The proportion of indications rated with disagreement was 4% for PTCA and 7% for CABG. Conclusion: Multinational panels appear to be a feasible method of addressing issues concerning the appropriateness and necessity of medical procedures in western European countries. The criteria produced provide a common tool that can be used to measure the overuse and underuse of medical procedures and to guide decision-making.

Key Words: Coronary revascularization • Coronary artery bypass grafting • Percutaneous transluminal coronary angioplasty • Appropriateness • Necessity

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