Diagnosis and Treatment of Coronary Disease

Two panels of doctors, one in the USA and one in the UK, were asked to indicate how appropriate they judged a series of possible indications for coronary angiography and coronary artery bypass graft (CABG) operations. Appropriateness was defined with respect to possible benefit to the patient and excluded considerations of cost. The indications were presented as a series of detailed clinical situations in which the procedure might be used, and for each indication individual panel members rated appropriateness on a scale of 1 to 9. The US panel judged more indications appropriate than did the UK panel, and there was more agreement among the members of the US panel than among those of the UK panel. Although the two panels tended to rate the appropriateness of the indications in the same order, the UK panel placed more emphasis than did the US panel on the importance of symptoms and the amount of medical treatment. Application of the panels' ratings to two groups of patients who had had coronary angiography showed that 17% and 27% of the investigations had been inappropriate by the standards of the US panel, whereas 42% and 60% were inappropriate by the UK panel ratings. 13% of the CABG operations studied were inappropriate by the US and 35% by the UK panel ratings.