Physicians give mixed angiography ratings
Is angiography worth doing?
For a recent study, 1,000 internists, family practi-tioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas were asked to rate the appropriateness of coronary angiography on a nine-point scale, ranging from extremely inappropriate (1), to uncertain (5), and extremely appropriate (9) for 20 common indications.1
Appropriateness was defined as the expected health benefits — increased life expectancy or functional capacity and relief of pain or anxiety —exceed the expected negative consequences —mortality, morbidity, pain, or anxiety associated with the procedure. Since angiography does not reduce morbidity or mortality, its benefit or harm is generally related to its effect on the subsequent use of medical therapy, angioplasty, or bypass surgery. The physicians were asked to assess the fol-lowing scenarios during initial hospitalizations for acute myocardial infarction of patients over 75, then patients under 75:
A. Within six hours of the onset of symptoms, the patient has not received thrombolytic therapy because of strong contraindications, and the myocardial infarction is uncomplicated.
B. Within six hours of the onset of symptoms, the patient has not received thrombolytic therapy because of strong contraindications and has per-sistent chest pain.
C. Within six hours of the onset of symptoms, the patient has not received thrombolytic therapy but has no strong contraindications, and the myocardial infarction is uncomplicated.
D. Within six hours of the onset of symptoms, the patient has not received thrombolytic therapy but has no strong contraindications and has per-sistent chest pain.
E. Within six hours of the onset of symptoms, the patient has received thrombolytic therapy, and the myocardial infarction is uncomplicated.
F. Within six hours of the onset of symptoms, the patient has received thrombolytic therapy and has persistent chest pain.
G. Between 12 hours after the onset of symp-toms and discharge, the patient has not received thrombolytic therapy, and the myocardial infarc-tion is uncomplicated.
H. Between 12 hours after the onset of symp-toms and discharge, the patient has not received thrombolytic therapy and has persistent chest pain.
I. Between 12 hours after the onset of symp-toms and discharge, the patient has not received thrombolytic therapy and has persistent pul-monary edema.
J. Between 12 hours after the onset of symp-toms and discharge, the patient has not received thrombolytic therapy and has stress-induced ischemia.
Indications K through T were phrased identi-cally for patients who were 75 or older.
For 17 of the 20 indications, the ratings of the surveyed physicians agreed within one unit on the nine-unit scale. Patients’ older age had no negative effect on ratings.
Cardiologists rated angiography as signifi-cantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who per-formed invasive procedures gave higher appro-priateness ratings for angiography than did cardiologists who did not perform such proce-dures and primary care physicians. For uncom-plicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than did physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than did other physicians.
Reference
1. Ayanian JZ, Landrum MB, Normand ST, et al. Rating the appropriateness of coronary angiography. N Engl J Med 1998; 338:1,896-1,904.
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