European criteria for the appropriateness and necessity of coronary revascularization procedures

Objectives: Large variations in the use of coronary revascularization proce dures have led many countries to apply the RAND appropriateness method to d evelop specific criteria describing patients who should be offered these pr ocedures. The method is based on the work of a multidisciplinary expert pan el that reviews a synthesis of the scientific evidence and rates the approp riateness of a comprehensive list of indications for the procedure being st udied. Previous studies, however, have all involved single-country panels. We tested the feasibility of carrying out a multinational panel to rate the appropriateness and necessity of coronary revascularization, thereby produ cing recommendations for common European criteria. Methods: Using the RAND methodology, a multispecialty (interventional cardiologists, non-interventi onal cardiologists and cardiovascular surgeons), multinational (The Netherl ands, Spain, Sweden, Switzerland and the United Kingdom) panel rated the ap propriateness and necessity of indications for percutaneous transluminal co ronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). A synthesis of the evidence and list of indications for PTCA and CABG were sent to 15 panelists, three from each country, who performed their ratings in three rounds. Results: For PTCA, 24% of the indications were appropriate and necessary, 16% were appropriate, 43% were uncertain and 17% were inapp ropriate. The corresponding values for CABG were 33% appropriate and necess ary, 7% appropriate, 40% uncertain and 20% inappropriate. The proportion of indications rated with disagreement was 4% for PTCA and 7% for CABG. Concl usion: Multinational panels appear to be a feasible method of addressing is sues concerning the appropriateness and necessity of medical procedures in western European countries. The criteria produced provide a common tool tha t can he used to measure the overuse and underuse of medical procedures and to guide decision-making. (C) 2000 Elsevier Science B.V. All rights reserv ed.