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The Appropriateness of Coronary Artery Bypass Graft Surgery in Academic Medical Centers

Lucian L. Leape, MD; Lee H. Hilborne, MD, MPH; J. Sanford Schwartz, MD; David W. Bates, MD, MSc; Haya R. Rubin, MD, PhD; Peter Slavin, MD; Rolla Edward Park, PhD; David M. Witter Jr., BA; Robert J. Panzer, MD; Robert H. Brook, MD, ScD, The Working Group of the Appropriateness Project of the Academic Medical Center Consortium*
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Acknowledgments: The authors thank the Appropriateness Initiative project manager, Caren Kamberg, MSPH (RAND Corporation), without whom this project could not have been carried out. Grant Support: In part by research grants from the Commonwealth Fund, the John A. Hartford Foundation, and the American Medical Association. Requests for Reprints: Lucian L. Leape, MD, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. Current Author Addresses: Dr. Leape: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;125(1):8-18. doi:10.7326/0003-4819-125-1-199607010-00003
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Objective: To compare the appropriateness of use of coronary artery bypass graft [CABG] surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases.

Design: Retrospective, randomized medical record review.

Setting: 12 Academic Medical Center Consortium hospitals.

Patients: Random sample of 1156 patients who had had isolated CABG surgery in 1990.

Main Outcome Measures: 1] Percentage of patients with indications for which CABG surgery was classified as appropriate, inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review.

Results: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02).

*For a listing of additional members of the Working Group of the Appropriateness Project of the Academic Medical Center Consortium, see the Appendix.


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Figure 1. Operations for left main disease (290 patients) or three-vessel disease (613 patients) were more likely to be classified as necessary or appropriate than were those for two-vessel disease (195 patients) or one-vessel disease (58 patients).
Appropriateness of coronary artery bypass graft surgery by vessel.
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Figure 2. The percentage of cases classified as necessary or appropriate ranged from 85% to 96%. Rates of inappropriate use ranged from 0% to 5%.
Appropriateness of coronary artery bypass graft by hospital.
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Figure 3. The number of indications that were upgraded ( = 503) far exceeded the number that were downgraded ( = 65). However, the number of cases affected by these changes was relatively small: When the surgeons' ratings of appropriateness were substituted for the RAND expert panel ratings, ratings were upgraded in 23 cases and downgraded in 27. No case was reclassified from inappropriate to appropriate as a result of the surgeons' revisions.
Effect of revisions of ratings by surgeons.nn
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Appendix Figure 1. Sample page of Rand Corporation ratings for the appropriateness of coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) for a patient with severe chronic stable angina. ECG equals electrocardiogram; Pt equals patient.
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