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Rating the appropriateness of coronary angiography--do practicing physicians agree with an expert panel and with each
J Z Ayanian1, M B Landrum, S L Normand
1Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
Background:
Evaluations of the appropriateness of medical care are important to monitor the quality of care and to contain costs and enhance safety by reducing inappropriate care. Experts' views are usually incorporated into evaluations of appropriateness. However, practicing physicians may not concur with these views, and physicians' clinical backgrounds may influence their beliefs.
Methods:
We asked 1058 internists, family practitioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas to rate the appropriateness of coronary angiography after acute myocardial infarction for 20 common indications. Nine clinical experts also rated these indications using an established consensus method.
Results:
For 17 of the 20 indications, median ratings of surveyed physicians and the expert panel agreed within 1 unit on a 9-unit scale. Patients' older age had a negative effect on ratings by the expert panel but not on ratings by surveyed physicians. In multivariable analyses of surveyed physicians, cardiologists rated angiography as significantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who performed invasive procedures gave higher appropriateness ratings for angiography than did cardiologists who did not perform such procedures and primary care physicians. For uncomplicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than other physicians.
Conclusions:
Surveyed physicians agreed with clinical experts about the appropriateness of coronary angiography after myocardial infarction for most indications, indicating that well-designed expert panels can closely reflect the views of practicing physicians. Variations in beliefs among practicing physicians suggest that evaluations of medical practice should incorporate the views of a range of relevant types of physicians.