Appropriateness Criteria for Coronary Angiography in Angina

Reliability and Validity

Published In: Annals of Internal Medicine, v. 149, no. 4, Aug. 19, 2008, p. 221-231

Posted on RAND.org on December 31, 2007

by Harry Hemingway, Ruoling Chen, Cornelia Junghans, Adam Timmis, Sandra Eldridge, Nick Black, Paul G. Shekelle, Gene Feder

Read More

Access further information on this document at www.annals.org

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

BACKGROUND: Evaluated criteria for tailoring the decision to perform coronary angiography in specific clinical scenarios are lacking. OBJECTIVE: To determine the reliability and prognostic validity of patient-specific appropriateness criteria for coronary angiography among patients with suspected angina pectoris. DESIGN: Prospective observational study. Two independent panels of clinicians scored 2400 patient-specific indications for coronary angiography as inappropriate, uncertain, or appropriate. Using a simple computer algorithm, patients were matched to 1 of these indications. SETTING: 6 urban ambulatory care clinics in the United Kingdom. PATIENTS: 9356 consecutive patients with recent-onset chest pain in whom stable angina was suspected. MEASUREMENTS: Appropriateness ratings and clinical outcomes (coronary death and acute coronary syndrome events) over a median of 3 years of follow-up. RESULTS: 660 coronary deaths or acute coronary syndrome events occurred. Agreement between the 2 panels (reliability) on appropriateness category was moderate (weighted = 0.58; P < 0.001). Use of subsequent angiography was strongly related to appropriateness category (P for linear trend <0.001) according to scores from either panel. Among patients judged as appropriate candidates for angiography, underuse was common (57% according to panel A and 71.3% according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure. The hazard ratio after adjustment for age, sex, exercise electrocardiography result, and secondary prevention medication was similar according to panel A (2.78 [95% CI, 1.77 to 4.37]) and panel B (2.47 [CI, 1.72 to 3.55]). LIMITATION: The study was too small to assess the relationship of angiography with coronary death and did not assess the reasons why patients did not receive angiography. CONCLUSION: Appropriateness scores offer prognostically valid criteria for judging which specific patients might benefit from coronary angiography. Patient-specific appropriateness scores help pinpoint areas where judgments diverge and are a promising tool for making guidelines more effective.

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 www.rand.org/about/principles.

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.