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Relationship of Anatomic Disease to Appropriateness Ratings of Coronary Angiography

Susan J. Noonan, MD, MPH; Jan L. Cook, MD, MPH; Candace E. Keller, MD, MPH; Carla M. Rosenkrans, RN, BSN; Joseph M. Healy Jr, PhD; Lisa Feingold, MSPH; Stephen C. Schoenbaum, MD, MPH
Arch Intern Med. 1995;155(11):1209-1213. doi:10.1001/archinte.1995.00430110129014.
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Background:  At Harvard Community Health Plan (HCHP), Brookline, Mass, a mixed-model health maintenance organization (HMO), coronary angiography is performed at numerous community and tertiary-level teaching hospitals.

Objective:  To determine the appropriateness of coronary angiography within HCHP according to RAND (1992) criteria and to examine the relationship between the appropriateness rating and (1) the clinical indication for catheterization and (2) the extent of anatomic disease.

Method:  A retrospective, randomized hospital medical record review of 292 patients enrolled in HCHP who underwent coronary angiography in 1992, stratified by four distinct HCHP subgroups.

Results:  Of the coronary angiographies reviewed, 78% were rated appropriate, 16% uncertain, and only 6% inappropriate across the entire sample. Ratings were comparable in all subdivisions of HCHP despite an incidence rate of catheterization in one of the three HMO divisions that was 60% and 40% higher than in the other two divisions. The lowest appropriateness ratings were for Asymptomatic patients (43%) and those with Chest Pain of Uncertain Origin (35%) (capital letters refer to the RAND clinical indication criteria mentioned above). A rating of necessity was not a better discriminator of anatomic disease than a rating of appropriateness alone: 82% and 84%, respectively, were found to have disease by angiography.

Conclusion:  The low HCHP rate of inappropriateness for coronary angiography is comparable with the RAND 1992 New York State data. This finding, coupled with marked differences in the incidence rate of this procedure among the HCHP divisions, is consistent with either major differences in the sickness of the HMO's subpopulations or, more likely, a lack of specificity of the RAND criteria for coronary angiography.(Arch Intern Med. 1995;155:1209-1213)


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