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Validation of the Appropriate Use Criteria for Coronary Angiography: A Cohort StudyValidation of the Appropriate Use Criteria for Coronary Angiography

Michael M. Mohareb, MD; Feng Qiu, MSc; Warren J. Cantor, MD; Kori J. Kingsbury, MSN, MPA; Dennis T. Ko, MD, MSc; and Harindra C. Wijeysundera, MD, PhD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 10 March 2015.

From Sunnybrook Health Sciences Centre, University of Toronto, Institute for Clinical Evaluative Sciences, and Cardiac Care Network of Ontario, Toronto, and Southlake Regional Health Centre, Newmarket, Ontario, Canada.

Note: Dr. Wijeysundera had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors acknowledge that the clinical registry data used in this publication are from the CCN of Ontario and its member hospitals. The CCN of Ontario serves as an advisory body to the MOHLTC and is dedicated to improving the quality, efficiency, access, and equity of adult cardiovascular services in Ontario.

Financial Support: By the ICES, which is funded by an annual grant from the Ontario MOHLTC. The funding agencies were the Canadian Institutes of Health Research, the Schulich Heart Centre, and the Sunnybrook Research Institute. Dr. Wijeysundera was supported by a Distinguished Clinician Scientist Award from the Heart and Stroke Foundation of Canada. Dr. Ko was supported by a Phase 2 Clinician Scientist Award from the Ontario Provincial Office of the Heart and Stroke Foundation.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1889.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Wijeysundera (e-mail, harindra.wijeysundera@sunnybrook.ca). Data set: Not available.

Requests for Single Reprints: Harindra C. Wijeysundera, MD, PhD, Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, Ontario M4N 3M5, Canada.

Current Author Addresses: Drs. Mohareb and Wijeysundera: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, Ontario M4N 3M5, Canada.

Mr. Qiu and Dr. Ko: Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.

Dr. Cantor: Southlake Regional Health Centre, Medical Arts Building, 681 Davis Drive, Suite 602, Newmarket, Ontario L3Y 2P6, Canada.

Ms. Kingsbury: Cardiac Care Network of Ontario, 4100 Yonge Street, Suite 502, Toronto, Ontario M2P 2B5, Canada.

Author Contributions: Conception and design: M.M. Mohareb, K.J. Kingsbury, D.T. Ko, H.C. Wijeysundera.

Analysis and interpretation of the data: M.M. Mohareb, F. Qiu, D.T. Ko, H.C. Wijeysundera.

Drafting of the article: M.M. Mohareb, H.C. Wijeysundera.

Critical revision of the article for important intellectual content: W.J. Cantor, D.T. Ko, H.C. Wijeysundera.

Final approval of the article: M.M. Mohareb, W.J. Cantor, D.T. Ko, H.C. Wijeysundera.

Provision of study materials or patients: K.J. Kingsbury.

Obtaining of funding: K.J. Kingsbury, H.C. Wijeysundera.

Administrative, technical, or logistic support: K.J. Kingsbury.

Ann Intern Med. 2015;162(8):549-556. doi:10.7326/M14-1889
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Background: The use of invasive coronary angiography in stable ischemic heart disease (IHD) varies widely.

Objective: To validate the 2012 appropriate use criteria for diagnostic catheterization by examining the relationship between the appropriateness of cardiac catheterization in patients with suspected stable IHD and the proportion of patients with obstructive coronary artery disease (CAD) and subsequent revascularization.

Design: Population-based, observational, multicenter cohort study.

Setting: The Cardiac Care Network, a registry of all patients having elective angiography at 18 hospitals in Ontario, Canada, between 1 October 2008 and 30 September 2011.

Patients: Persons without prior coronary revascularization or myocardial infarction who had angiography for suspected stable CAD.

Measurements: Appropriateness scores were ascertained by using data collected at the time of the index angiography and were categorized as appropriate, inappropriate, or uncertain.

Results: Among the final cohort of 48 336 patients, 58.2% of angiographic studies were classified as appropriate, 10.8% were classified as inappropriate, and 31.0% were classified as uncertain. Overall, 45.5% of patients had obstructive CAD. In patients with appropriate indications for angiography, 52.9% had obstructive CAD, with 40.0% undergoing revascularization. In those with inappropriate indications, 30.9% had obstructive CAD and 18.9% underwent revascularization; in those with uncertain indications, 36.7% had obstructive CAD and 25.9% had revascularization. Although more patients with appropriate indications had obstructive CAD and underwent revascularization (P < 0.001), a substantial proportion of those with inappropriate or uncertain indications had important coronary disease.

Limitation: Data were not available on whether symptoms were atypical.

Conclusion: 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.

Primary Funding Source: Canadian Institutes of Health Research.


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Figure 1.

Assignment of appropriateness scores according to the AUC.

Indications are from Tables 1.2 and 1.3 in the AUC document (7). AUC = appropriate use criteria for diagnostic catheterization; GXT = stress echocardiographic testing; LV = left ventricular.

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Figure 2.

Study flow diagram.

CABG = coronary artery bypass grafting; CAD = coronary artery disease; MI = myocardial infarction; PCI = percutaneous coronary intervention.

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Figure 3.

Angiography appropriateness and diagnostic yield, by physician and hospital factors.

The comparison of appropriateness between interventional and noninterventional physicians was statistically significant (P < 0.001), as was the comparison among the 3 types of hospitals (P < 0.001). The comparison of proportions of patients with obstructive CAD between physician and hospital types was also statistically significant (P < 0.001). “Intervent” refers to a physician who performs both diagnostic catheterization and PCI. “Nonintervent” refers to a physician who performs only diagnostic catheterization. “Cath” refers to a hospital that performs only on-site diagnostic catheterization, “Cath and PCI only” refers to a hospital that also performs on-site PCI but not CABG, and “Cath, PCI, and CABG” refers to a hospital that also performs on-site CABG. CABG = coronary artery bypass grafting; CAD = coronary artery disease; PCI = percutaneous coronary intervention.

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Appendix Figure.

Variation in appropriateness category across hospitals.

CAD = coronary artery disease.

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Implications of Appropriateness Criteria
Posted on May 9, 2015
Isbah Barlas,Taha Baig, Asad Qamar,Abbas S Ali
Institute of Cardiovascular Excellence
Conflict of Interest: None Declared
Mohareb et. al, in their article, found a third of patients deemed inappropriate to have obstructive coronary disease and a fifth who went on to undergo revascularization procedures. Appropriateness criteria are guidelines compiled by different societies and organizations . As stated in the preface to the document, the American College of Cardiology states “Although not intended to be entirely comprehensive, the indications are meant to identify common scenarios encompassing the majority of contemporary practice.” However, in current clinical practice, payers and regulatory agencies routinely deny procedures citing these specified criteria. Data from Mohareb’s study raises a question with regard to the wisdom of adopting such criteria in the absence of proper analyses, outcomes or randomized trials of therapy per AUC versus therapy per clinical instinct.

We report a short case series of patients who underwent peripheral arterial intervention (PTA), all of whom were deemed initially inappropriate to highlight this issue. 48 of 70 patients deemed to have undergone allegedly unnecessary PTA had images wherein both sides of soft tissue were visible. Using a visible calibration catheter, calf circumference was measured from these films. Calf circumference tape measurement data from NHANES patients with ABI >0.9 and <1.3 formed the control group. The data shows a 12 cm tissue loss evident among the PTA patients (24+/-2 cm) compared to NHANES normal patients (37.9 +/- 0.05 cm) (see figure) with a significant p- value (8.040298e-09). Therefore, published guidelines used without an in-depth understanding in this instance led to the belief that the procedures of these 40 patients were not indicated, when in fact they did showcase significant measurable tissue loss to the tune of 12 cm. The issues arises here regarding other potential repeats as in this case, in which a reliance on established guidelines without further analyses could potentially be detrimental to patient health.

In clinical practice, initially referring to published guidelines is a reliable stepping-stone, however it should not be the end-all means regarding clinical diagnosis, as a sole reliance on these guidelines can be misleading at times. We commend Mohareb et al in their effort to assess the validity of appropriateness criteria. Further studies on the methodology of such criteria and their utility in clinical practice are needed. Finally, there is no substitute for experience and clinical judgment; in the world of evidence-based medicine and guideline driven testing, our patients can become collateral damage.
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