Appropriateness of referral of coronary angiography patients in Sweden

Objective-To evaluate the appropriateness of referral following coronary an giography in Sweden. Design-Prospective survey and review of medical records. Patients-Consecutive series of 2767 patients who underwent coronary angiogr aphy in Sweden between May 1994 and January 1995 and were considered for co ronary revascularisation. Main outcome measures-Percentage of patients referred for coronary artery b ypass graft surgery (CABG) and percutaneous transluminal coronary angioplas ty (PTCA) for indications that were judged necessary, appropriate, uncertai n, and inappropriate by a multispecialty Swedish national expert panel usin g the RAND/University of California Los Angeles (UCLA) appropriateness meth od, and the percentage of patients referred for continued medical managemen t who met necessity criteria for revascularisation. Results-Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78 % of patients, uncertain for 12% and inappropriate for 10%. For PTCA the fi gures were 32%, 30% and 38%, respectively. Two factors contributed to the h igh inappropriate rate. Many of these patients did not have ((significant)) coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of pa tients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical ther apy Conclusions-Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revasc ularisation judged inappropriate. Since some cardiovascular procedures evol ve rapidly, the proportion of patients referred for inappropriate indicatio ns today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisati on and ensure that they are appropriately treated.