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[The appropriateness of diagnostic angiography in cardiology]
Guglielmo Bernardi1, Giorgio Morocutti, Leonardo Spedicato
1Dipartimento di Scienze Cardiovascolari U.O. di Cardiologia Azienda Ospedaliera S. Maria della Misericordia Piazzale S. Maria della Misericordia, 15, 33100 Udine. guglbern@tin.it
Insights
Coronary angiography use shows geographic variations, with both overuse and underuse concerns. Improving appropriateness requires better physician and patient education, and clearer guidelines for this vital cardiac diagnostic test.
Area of Science:
- Cardiology
- Health Services Research
- Medical Diagnostics
Background:
- Coronary angiography is a common invasive diagnostic procedure with documented regional variations in use.
- Appropriateness of use is crucial, balancing potential benefits against risks, and is influenced by facility availability.
- Historical data show consistent appropriateness rates (75%) but shifts in procedure classification (fewer inappropriate, more uncertain).
Purpose of the Study:
- To analyze factors influencing the appropriateness of coronary angiography.
- To investigate trends in both overuse and underuse of coronary angiography.
- To identify strategies for improving the appropriate utilization of this cardiac procedure.
Main Methods:
- Review of observational and randomized studies on coronary angiography utilization and appropriateness.
- Analysis of factors such as patient demographics, clinical presentation, and healthcare system characteristics.
- Examination of trends in procedure appropriateness over time and across different healthcare settings.
Main Results:
- Appropriateness rates for coronary angiography remained stable around 75% from 1980-1995, with varying classifications of procedures.
- Factors influencing appropriateness include patient age, angina severity, medical therapy, exercise test results, and income.
- Recent data indicate underuse in hospitals without catheterization facilities and among uninsured patients, with suboptimal patient selection and lower use in low-risk populations.
Conclusions:
- Variability in expert opinions significantly impacts appropriateness assessments.
- Underuse of coronary angiography, particularly in certain patient groups and settings, is a growing concern with potential negative impacts on outcomes.
- Improving coronary angiography utilization necessitates enhanced education, further research, simplified guidelines, and strict adherence to necessity criteria for patient access.
Abstract:
Coronary angiography is the most frequently performed invasive diagnostic test in the western world, but regional differences are common and have been outlined in both observational and randomized studies. Appropriateness evaluation is hence fundamental, as the use of invasive cardiac procedures is strongly associated with the population-based availability of catheterization facilities. A procedure is judged appropriate if the expected health benefit exceeds the possible negative consequences by a sufficiently wide margin; it is necessary when not performing it could result in harm for the patient. In the first period (1980-1995) researchers seemed to try to find an explanation for geographic variations regarding overuse: the appropriateness remained at the same level through time (75%), while a trend towards a reduction in the number of inappropriate procedures (< or = 20%) and an increase in that of the uncertain ones was evident. The different opinions of the expert panels constituted the major cause of variability. The factors mainly affecting the appropriateness were advanced age, angina class, intensity of medical therapy, exercise test results and income. Canadians and Europeans seemed to request a higher standard of scientific evidence as compared to US doctors; surgeons tended to give higher scores than cardiologists and internists. Inappropriate indications were similar in high- and low-use hospitals. More recently, important data emerged on the lower than necessary use of this procedure and this was more evident in hospitals without on-site catheterization facilities and in patients without fee-for-service insurance. Patient selection was suboptimal and coronary angiography was more frequently performed in low-risk populations. This phenomenon is of concern, because the lower than necessary use of indicated procedures can bear on the patients' outcome. In fact, an inverse relationship between mortality and coronary angiography use has been observed, especially in patients in whom it has been judged necessary. No lower than necessary use of differences in appropriateness have been found in females, but this is possible in ethnic minorities. If the appropriateness is to be improved, specific actions have to be directed to increase the know-how of doctors, patients, and administrators, to promote research in the fields where knowledge is still missing and to implement simplified guidelines and appropriateness criteria, in order to favor a more extensive use. It is mandatory to assess the necessity of coronary angiography procedures and to grant access to those patients who meet the necessity criteria.