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Appropriateness Criteria for Coronary Angiography in Angina: Reliability and Validity

Harry Hemingway, MBBChir; Ruoling Chen, MD; Cornelia Junghans, PhD; Adam Timmis, MBBChir; Sandra Eldridge, PhD; Nick Black, MD; Paul Shekelle, MD; and Gene Feder, MD
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From University College London Medical School, Barts and the London NHS Trust, Queen Mary's School of Medicine and Dentistry, and London School of Hygiene and Tropical Medicine, London, United Kingdom, and Greater Los Angeles Veterans Affairs Health Care System, Los Angeles, California.

Acknowledgment: The authors thank the members of the 2 panels: specialists Khalid Barakat (Wexham Park), Alison Calver (Southampton), Kieron Daly (Galway), Mary Heber (Telford), Rob Henderson (Nottingham), Diana Holdright (London), Bruce Keogh (Birmingham), Patrick Magee (London), Stuart Pringle (Dundee), Jeremy Sayer (Harlow), Jane Skinner (Newcastle), and Adam Timmis (London) and family physicians Naureen Bhatti (London), Peter Brindle (Bristol), Nick Dunn (Southampton), Martin Eccles (Newcastle), Tom Fahey (Dundee), Gene Feder (London), Richard McManus (Birmingham), Andrew Murphy (Galway), Neville Purssell (London), and Judy Shakespeare (Oxford).

Grant Support: By the United Kingdom Department of Health's Policy Research Programme and the NHS Research and Development Service Delivery and Organisation Programme. Dr. Hemingway was supported by a Public Health Career Scientist Award from the Department of Health.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol: Published elsewhere (11). Statistical code: Available from Dr. Chen (e-mail, ruoling.chen@ucl.ac.uk). Data set: Requests to use the data set for research should be directed to Dr. Timmis (e-mail, adamtimmis@mac.com).

Requests for Single Reprints: Harry Hemingway, MBBChir, University College London Medical School, 1-19 Torrington Place, London WC1E 6BT, United Kingdom; e-mail, h.hemingway@ucl.ac.uk.

Current Author Addresses: Drs. Hemingway, Chen, and Junghans: Department of Epidemiology and Public Health, University College London Medical School, 1-19 Torrington Place, London WC1E 6BT, United Kingdom.

Dr. Timmis: Department of Cardiology, The London Chest Hospital, Barts and the London NHS Trust, Bonner Road, London E2 9JX, United Kingdom.

Dr. Eldridge: Centre for Health Sciences, Barts and the London NHS Trust, Queen Mary's School of Medicine and Dentistry, Old Medical College Building, Turner Street, London E1 2AD, United Kingdom.

Dr. Black: Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.

Dr. Shekelle: RAND Health, Evidence-based Practice Center, 1776 Main Street, Santa Monica, CA 90407.

Dr. Feder: Academic Unit of Primary Care, University of Bristol, 25 Belgrave Road London BS8 2AA, United Kingdom.

Author Contributions: Conception and design: H. Hemingway, C. Junghans, A. Timmis, N. Black, P. Shekelle, G. Feder.

Analysis and interpretation of the data: H. Hemingway, R. Chen, C. Junghans, A. Timmis, S. Eldridge, G. Feder.

Drafting of the article: H. Hemingway, S. Eldridge.

Critical revision of the article for important intellectual content: H. Hemingway, C. Junghans, A. Timmis, S. Eldridge, N. Black, P. Shekelle, G. Feder.

Final approval of the article: H. Hemingway, R. Chen, C. Junghans, A. Timmis, S. Eldridge, N. Black, P. Shekelle, G. Feder.

Provision of study materials or patients: A. Timmis.

Statistical expertise: R. Chen, S. Eldridge.

Obtaining of funding: H. Hemingway, C. Junghans.

Collection and assembly of data: H. Hemingway, S. Eldridge, A. Timmis.

Ann Intern Med. 2008;149(4):221-231. doi:10.7326/0003-4819-149-4-200808190-00003
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We developed and rated new scores for the appropriateness of coronary angiography for suspected angina and found that agreement between 2 independent panels was moderate. Among more than 9000 consecutive ambulatory patients with chest pain presenting for initial cardiologic assessment, each panel's scores strongly predicted receipt of subsequent angiography. Among patients in whom angiography was deemed appropriate by either panel, those who did not undergo coronary angiography had higher coronary event rates. In the ongoing absence of randomized clinical outcome trials of different investigation strategies among patients with suspected angina pectoris, the appropriateness method is an important tool for decision support in individual patients and for assessing quality of care in groups of patients.

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Figure 1.
Study flow diagram.

ACS = acute coronary syndrome; CHD = coronary heart disease.

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Figure 2.
Use of angiography, by appropriateness ratings by panel A and panel B.
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Appendix Figure.
Cumulative probability of coronary heart disease (CHD) death or acute coronary syndrome (ACS) events according to receipt of coronary angiography among candidates judged appropriate by panel A and panel B.
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