Appropriateness of the Use of Cardiovascular Procedures

Resources available to provide adequate health care in western countries must compete with other priorities such as education and the environment. At the same time the allocation of health resources often does not correspond to the real needs of patients. We have developed a method that combines what is known in the literature with expert physician judgment to generate clinically valid appropriateness guidelines. The method involves a modified Delphi approach, including a detailed literature review, consultations with experts, and three rounds of panel ratings. Clinical scenarios, or indications, are rated appropriate, uncertain, or inappropriate. Appropriate means that the procedure is worth doing for the given indication if the health benefit exceeds the health risk. We have conducted panels relating to coronary procedures in four countries. Application of the indications to individual cases has demonstrated that the amount of inappropriate care is too large to be ignored. Dissemination of appropriateness results might take the form of public disclosure or as part of the physician/patient exchange to improve performance. Indications for which a procedure is frequently performed and which are rated uncertain should be considered to be the focus of controlled clinical trials.