1
|
Mohareb MM, Qiu F, Cantor WJ, Kingsbury KJ, Ko DT, Wijeysundera HC. Validation of the appropriate use criteria for coronary angiography: a cohort study. Ann Intern Med 2015; 162:549-56. [PMID: 25751586 DOI: 10.7326/m14-1889] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Michael M. Mohareb
- 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
| | - Feng Qiu
- 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
| | - Warren J. Cantor
- 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
| | - Kori J. Kingsbury
- 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
| | - Dennis T. Ko
- 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
| | - Harindra C. Wijeysundera
- 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
| |
Collapse
|
2
|
Wijeysundera HC, Qiu F, Bennell MC, Natarajan MK, Cantor WJ, Smith S, Kingsbury KJ, Ko DT. Impact of system and physician factors on the detection of obstructive coronary disease with diagnostic angiography in stable ischemic heart disease. Circ Cardiovasc Qual Outcomes 2014; 7:648-55. [PMID: 25185246 DOI: 10.1161/circoutcomes.114.001098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wide variation exists in the detection rate of obstructive coronary artery disease (CAD) with elective coronary angiography for suspected stable ischemic heart disease. We sought to understand the incremental impact of nonclinical factors on this variation. METHODS AND RESULTS We included all patients who underwent coronary angiography for possible suspected stable ischemic heart disease, from October 1, 2008, to September 30, 2011, in Ontario, Canada. Nonclinical factors of interest included physician self-referral for angiography, the physician type (invasive or interventional), and hospital type. Hospitals were categorized into diagnostic angiogram only centers, stand-alone percutaneous coronary intervention centers, or full service centers with coronary artery bypass surgery available. Multivariable hierarchical logistic models were developed to identify system and physician-level predictors of obstructive CAD, after adjustment for patient factors. Our cohort consisted of 60 986 patients, of whom 31 726 had obstructive CAD (52.0%), with significant range across hospitals from 37.3% to 69.2%. Fewer self-referral patients (49.8%) had obstructive CAD compared with nonself-referral patients (53.5%), with an odds ratio of 0.89 (95% confidence interval, 0.86-0.93; P<0.001). Angiograms performed by invasive physicians had a lower likelihood of obstructive CAD compared with those by interventional physicians (48.2% versus 56.9%; odds ratio, 0.85; 95% confidence interval, 0.81-0.90; P<0.001). Fewer angiograms at diagnostic only centers showed obstructive CAD (42.0%) compared with full service centers (55.1%; odds ratio, 0.62; 95% confidence interval, 0.39-0.98; P=0.04). Nonclinical factors accounted for 23.8% of the variation between hospitals. CONCLUSIONS Physician and system factors are important predictors of obstructive CAD with coronary angiography.
Collapse
Affiliation(s)
- Harindra C Wijeysundera
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.).
| | - Feng Qiu
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| | - Maria C Bennell
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| | - Madhu K Natarajan
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| | - Warren J Cantor
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| | - Stuart Smith
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| | - Kori J Kingsbury
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| | - Dennis T Ko
- From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W, M.C.B., D.T.K.) and Institute of Health Policy, Management, and Evaluation (H.C.W., D.T.K.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.C.W., F.Q., D.T.K.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Hamilton Health Sciences Centre, Hamilton, Ontario, Canada (M.K.N.); Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.); St Mary's Hospital, Kitchener, Ontario, Canada (S.S.); and Cardiac Care Network of Ontario, North York, Ontario, Canada (K.J.K.)
| |
Collapse
|