Assessment of priority for coronary revascularisation procedures

Abstract To develop guidelines for ranking the urgency with which patients with angiographically proven coronary disease need revascularisation procedures, factors that a panel of cardiac specialists agreed were likely to affect urgency were incorporated into 438 fictitious case-histories. Each panelist then rated the cases on a 7-point scale based on maximum acceptable waiting time for surgery; 1 on the scale represented emergency surgery and 7 delays of up to 6 months. For only 1% of cases was there agreement on a single rating by at least 12/16 panelists. Results of this ranking exercise were used by the panel to draw up triage guidelines. The three main urgency determinants were severity and stability of symptoms of angina, coronary anatomy from angiographic studies, and results of non-invasive tests for risk of ischaemia. Together these three factors generally gave an urgency rating for any given case to within less than 0·25 scale points of the value predicted with all factors. A numerical scoring system was derived to permit rapid estimation of the panel's recommended ratings.

[1]  E. K. Weir,et al.  Practical problems in assessing risk for coronary artery bypass grafting. , 1985, The Journal of thoracic and cardiovascular surgery.

[2]  E F Cook,et al.  Comparative Reproducibility and Validity of Systems for Assessing Cardiovascular Functional Class: Advantages of a New Specific Activity Scale , 1981, Circulation.

[3]  E. Cook,et al.  Prospective Evaluation of a Clinical and Exercise-test Model for the Prediction of left Main Coronary Artery Disease , 1986, Medical decision making : an international journal of the Society for Medical Decision Making.

[4]  T. David,et al.  The changing pattern of coronary artery bypass surgery. , 1989, Circulation.

[5]  B. Gersh,et al.  Randomized trials in coronary artery bypass surgery. , 1987, Progress in cardiovascular diseases.

[6]  R H Brook,et al.  A Method for the Detailed Assessment of the Appropriateness of Medical Technologies , 1986, International Journal of Technology Assessment in Health Care.

[7]  R. Brook,et al.  DIAGNOSIS AND TREATMENT OF CORONARY DISEASE: COMPARISON OF DOCTORS' ATTITUDES IN THE USA AND THE UK , 1988, The Lancet.

[8]  F. Harrell,et al.  Exercise treadmill score for predicting prognosis in coronary artery disease. , 1987, Annals of internal medicine.

[9]  G. Beller,et al.  Sensitivity, specificity, and prognostic significance of noninvasive testing for occult or known coronary disease. , 1987, Progress in cardiovascular diseases.

[10]  D. Berman,et al.  The efficacy of cardiovascular nuclear medicine exercise studies. , 1987, Seminars in nuclear medicine.

[11]  L. Campeau.  Letter: Grading of angina pectoris. , 1976, Circulation.

[12]  C. Naylor,et al.  Placing patients in the queue for coronary revascularization: evidence for practice variations from an expert panel process. , 1990, American journal of public health.

[13]  K. Kahn,et al.  Physician ratings of appropriate indications for six medical and surgical procedures. , 1986, American journal of public health.

[14]  R. Brook,et al.  Derivation of clinical indications for carotid endarterectomy by an expert panel. , 1987, American journal of public health.

[15]  J Lomas,et al.  The role of evidence in the consensus process. Results from a Canadian consensus exercise. , 1988, JAMA.

[16]  P. B. Kelly,et al.  Preoperative risk assessment in cardiac surgery: comparison of predicted and observed results. , 1987, The Annals of thoracic surgery.