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Appropriate use criteria for angiography may be inadequate decision-making guide
Appropriate use criteria for invasive coronary angiography often classify as inappropriate or uncertain studies of patients with coronary disease requiring treatment, according to a new analysis.
“Despite the association between appropriateness category and obstructive CAD, this study raises concerns about the ability of the [appropriate use criteria] to guide clinical decision-making,” researchers wrote in the Annals of Internal Medicine.
Michael M. Mohareb, MD, and colleagues set out to validate the 2012 appropriate use criteria for diagnostic catheterization by examining the relationship between the appropriateness of cardiac catheterization in patients with obstructive CAD and later revascularization.
They analyzed 48,336 patients who underwent elective angiography for suspected stable CAD at 18 hospitals in Ontario, Canada, between October 2008 and September 2011. All patients had no prior MI or coronary revascularization.
Mohareb, from the University of Toronto, and colleagues found that, in the cohort, 58.2% of angiographic studies were classified as appropriate by the 2012 criteria, 10.8% were classified as inappropriate and 31% were classified as uncertain.
Overall, 45.5% of patients had obstructive CAD. Compared with those with inappropriate or uncertain indications, more patients with appropriate indications had obstructive CAD and underwent revascularization (P < .001), but “a substantial proportion of those with inappropriate or uncertain indications had important coronary disease,” Mohareb and colleagues wrote.
Specifically, in those with appropriate indications, 52.9% had obstructive CAD and 40% underwent revascularization; in those with inappropriate indications, 30.9% had obstructive CAD and 18.9% underwent revascularization; and in those with uncertain indications, 36.7% had obstructive CAD and 25.9% underwent revascularization, according to the researchers.
“We recommend caution in applying the [appropriate use criteria] in isolation for ranking specific cases or hospitals,” the researchers wrote. “However, finding obstructive disease does not necessarily mean the testing should have been done. In fact, the test is more meaningful when it finds normal coronary arteries in patients who would otherwise have been subjected to primary prevention medications and whose actual cause of symptoms would have been misdiagnosed.”
Manesh R. Patel
In a related editorial, Jacob A. Doll, MD, and Manesh R. Patel, MD, wrote that the findings “highlight the need for ongoing maintenance of [appropriate use criteria] with an iterative process that incorporates new evidence from clinical trials and quality improvement initiatives.”
Doll and Patel, both from Duke University Medical Center, wrote that: “Further work is needed to take full advantage of big data and build a learning health care system in which [appropriate use criteria] are seamlessly integrated into clinical care and policy. An ideal system would be evidence-based, use uniform and comprehensive clinical data, provide point-of-care decision support and aim to improve quality by reducing overuse and underuse. The [appropriate use criteria] could be the backbone of such a system.” – by Erik Swain
Disclosure: The researchers, Doll and Patel report no relevant financial disclosures.