RELATIONSHIP OF ANATOMIC DISEASE TO APPROPRIATENESS RATINGS OF CORONARY ANGIOGRAPHY

Background: At Harvard Community Health Plan (HCHP), Brookline, Mass, a mixed-model health maintenance organization (HMO), coronary angiogra phy is performed at numerous community and tertiary-level teaching hos pitals. Objective: To determine the appropriateness of coronary angiog raphy within HCHP according to RAND (1992) criteria and to examine the relationship between the appropriateness rating and (1) the clinical indication for catheterization and (2) the extent of anatomic disease. Method: A retrospective, randomized hospital medical record review of 292 patients enrolled in HCHP who underwent coronary angiography in 1 992, stratified by four distinct HCHP subgroups. Results: Of the coron ary angiographies reviewed, 78% were rated appropriate, 16% uncertain, and only 6% inappropriate across the entire sample. Ratings were comp arable in all subdivisions of HCHP despite an incidence rate of cathet erization in one of the three HMO divisions that was 60% and 40% highe r than in the other two divisions. The lowest appropriateness ratings were for Asymptomatic patients (43%) and those with Chest Pain of Unce rtain Origin (35%) (capital letters refer to the RAND clinical indicat ion criteria mentioned above). A rating of necessity was not a better discriminator of anatomic disease than a rating of appropriateness alo ne: 82% and 84%, respectively, were found to have disease by angiograp hy. Conclusion: The low HCHP rate of inappropriateness for coronary an giography is comparable with the RAND 1999 New York State data. This f inding, coupled with marked differences in the incidence rate of this procedure among the HCHP divisions, is consistent with either major di fferences in the sickness of the HMO's subpopulations or, more likely, a lack of specificity of the RAND criteria for coronary angiography.