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Indications for coronary revascularisation: a Dutch perspective
H Rigter1, A P Meijler, J McDonnell
1Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
Insights
This study assessed coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) indications. Experts found CABG more appropriate than PTCA for specific patient conditions, aiding guideline development.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Assessing the appropriateness of revascularization procedures is crucial for optimal patient care.
- Coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) are common interventions with varying indications.
- Establishing consensus on procedural appropriateness aids in developing clinical practice guidelines.
Purpose of the Study:
- To evaluate the appropriateness of indications for CABG surgery and PTCA.
- To compare the expert panel's preference between CABG, PTCA, and medical treatment across diverse clinical scenarios.
- To identify factors influencing the appropriateness ratings for these cardiac interventions.
Main Methods:
- A modified Delphi group judgment process involving 12 interventional cardiologists and cardiac surgeons from Dutch tertiary referral centers.
- Panelists rated 1182 model cases, representing various clinical features, on a 1-9 scale for indications of CABG vs. medical, PTCA vs. medical, and CABG vs. PTCA.
- Analysis focused on inter-panelist agreement, appropriateness scores, and treatment preferences (invasive vs. medical).
Main Results:
- The panel reached agreement on 58.6% of indications, with disagreement on 3.2%.
- Invasive treatment was preferred in 48.2% of cases, medical treatment in 22.8%, and no clear preference in 29.0%.
- Coronary artery bypass graft (CABG) was rated more appropriate than percutaneous transluminal coronary angioplasty (PTCA) when compared to medical treatment (35.4% vs. 21.6%, P < 0.001). Appropriateness varied with disease severity and lesion type (e.g., Type C lesions).
Conclusions:
- The Delphi panel method provides consistent scores for the appropriateness of medical procedure indications.
- This approach can serve as a valuable tool in the formulation of clinical practice guidelines for cardiovascular interventions.
- Expert consensus on indications for CABG and PTCA can help optimize treatment selection and improve patient outcomes.
Objective:
To assess the appropriateness of indications for coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA).
Methods:
A modified Delphi group judgement process with input from a panel of six interventional cardiologists and six cardiopulmonary surgeons. There was one clinician from each of the 12 tertiary referral heart centres in The Netherlands.
Main Outcome Measure:
Ratings by panel members, on a 1 to 9 scale, of indications presented as a choice between two treatments (CABG v medical treatment, PTCA v medical treatment, and CABG v PTCA) for 1182 model cases. Each case represented a unique combination of clinical features in terms of symptoms, medical history, and results of tests. Ratings were analysed with respect to degree of agreement among panelists, degree of appropriateness of indications, and panel's preference for invasive or medical treatment.
Results:
The panel agreed on 58.6% and disagreed on 3.2% of the indications. The panel opted for invasive treatment in 48.2% and medical treatment in 22.8%, and had no clear preference for either method in 29.0% of the cases. When compared with medical treatment, CABG was more often rated appropriate than PTCA: 35.4% v 21.6% (P < 0.001). Panel scores depended on severity of anatomical disease. For instance, for 51.5% of the model cases with one-vessel disease not including the proximal left anterior descending artery, the panel preferred medical treatment to invasive treatment, while the latter was preferred in 18% of the cases. In cases with type C lesions, the panel frequently rated PTCA as inappropriate. Panel scores were also affected by nonclinical factors. Cardiologists and surgeons rated the procedure of their own specialty higher than the alternative invasive intervention.
Conclusions:
The panel method yields logically consistent scores of the appropriateness of indications for carrying out medical procedures. It may be an aid in formulating clinical practice guidelines.