Measuring the Clinical Consistency of Panelists' Appropriateness Ratings

The Case of Coronary Artery Bypass Surgery

Published in: Health Policy, v. 42, no. 2, Nov. 1997, p. 135-143

Posted on on November 01, 1997

by Richard L. Kravitz, Rolla Edward Park, James P. Kahan

Read More

Access further information on this document at Health Policy

This article was published outside of RAND. The full text of the article can be found at the link above.

OBJECTIVE: To assess the clinical consistency of expert panelists' ratings of appropriateness for coronary artery bypass surgery. DESIGN: Quantitative analysis of panelists' ratings. PARTICIPANTS: Nine physicians (three cardiothoracic surgeons, four cardiologists, and two internists) convened by RAND to establish criteria for the appropriateness of coronary artery bypass surgery. MAIN OUTCOMES MEASURES: Percentage of indication-pairs given clinically inconsistent ratings (i.e. higher rating assigned to one member of an indication-pair when rating should have been equal or lower). RESULTS: In the final round of appropriateness ratings, among 1785 pairs of indications differing only on a single clinical factor (e.g., three-vessel vs. two-vessel stenosis), 6.6% were assigned clinically inconsistent ratings by individual panelists, but only 2.7% received inconsistent ratings from the panel as a whole (using the median panel rating as the criterion). Internists on the panel provided fewer inconsistent ratings (4.6%) than either cardiologists (7.8%) or cardiothoracic surgeons (6.3%) (p < 0.001). More inconsistencies were noted when the factor distinguishing otherwise identical indications was symptom severity (inconsistency rate, 13.2%) or intensity of medical therapy (13.2%) than when it was number of stenosed vessels (3.8%) or proximal left anterior descending (PLAD) involvement (1.9%). Contrary to expectations, panelists' inconsistency rates increased between the initial and final rounds of appropriateness ratings (from 3.9 to 6.6%, p < 0.001). Panelists' mean ratings across indications were only weakly correlated with individual inconsistency rates (r = 0.18, p = ns). CONCLUSIONS: The RAND/UCLA method for assessing the appropriateness of coronary revascularization generally produces criteria that are clinically consistent. However, research is needed to understand the sources of panelists' inconsistencies and to reduce inconsistency rates further.

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

Our mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior. To help ensure our research and analysis are rigorous, objective, and nonpartisan, we subject our research publications to a robust and exacting quality-assurance process; avoid both the appearance and reality of financial and other conflicts of interest through staff training, project screening, and a policy of mandatory disclosure; and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations, disclosure of the source of funding of published research, and policies to ensure intellectual independence. For more information, visit

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.