Bernstein Steven J, Lázaro Pablo, Fitch Kathryn, Aguilar María Dolores, Rigter Henk, Kahan James P
Veterans Affairs Health Services Research and Development Field Program, Ann Arbor, MI, USA.
Int J Qual Health Care. 2002 Apr;14(2):103-9. doi: 10.1093/oxfordjournals.intqhc.a002596.
We convened a multinational panel to develop appropriateness criteria for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG). To assess the applicability of these criteria, we applied them to patients referred for coronary revascularization. Finally, to understand how multinational criteria may differ from criteria developed by a panel of physicians from one country, we compared the appropriateness ratings using the multinational panel's criteria and those made using similar criteria previously developed by a panel of Dutch physicians.
We conducted a prospective survey and review of the medical records of 2363 consecutive patients presenting with chronic stable angina or following a myocardial infarction who were referred for PTCA (n=1137) or CABG (n= 1226) at ten Dutch hospitals performing coronary revascularization. Appropriateness was measured using two sets of criteria developed by: (1) a Dutch panel of cardiologists and cardiothoracic surgeons in 1991; and (2) a similarly composed European panel in 1998.
More PTCA referrals were rated inappropriate by Dutch criteria compared with multinational criteria among both patients with chronic stable angina (34.8 versus 6.1%; P< 0.001) and those with a recent myocardial infarction (28.1 versus 0.9%; P< 0.001). Among those patients referred for bypass surgery, the Dutch criteria judged a greater proportion of cases inappropriate than multinational criteria did for patients with chronic stable angina (3.7 versus 1.5%, P< 0.001). The proportion of cases rated inappropriate for bypass surgery among patients following a myocardial infarction was similar between the two panels (3.9 versus 2.4%, respectively; P=0.40). After reclassifying the data for two of the clinical factors used in the appropriateness criteria (lesion morphology and intensity of medical therapy) based on evidence that appeared in the literature after the Dutch panel met, we found no significant differences between the Dutch and multinational panels' appropriateness ratings.
While fewer cases were judged inappropriate using the multinational criteria compared with the Dutch criteria, the differences in ratings were related primarily to the clinical factors used by each panel. These findings support the review of appropriateness criteria, and other forms of clinical guidelines, to ensure that they are current with the clinical evidence before using them to assess clinical care. Developing such criteria using a multinational panel, in contrast to multiple single country panels, would be a more efficient use of resources.
我们召集了一个跨国专家小组来制定经皮腔内冠状动脉成形术（PTCA）和冠状动脉旁路移植术（CABG）的适宜性标准。为评估这些标准的适用性，我们将其应用于被转诊接受冠状动脉血运重建的患者。最后，为了解跨国标准与一个国家的医生小组制定的标准有何不同，我们使用跨国专家小组的标准和荷兰医生小组先前制定的类似标准对适宜性评级进行了比较。
我们对在十家进行冠状动脉血运重建的荷兰医院连续就诊的2363例慢性稳定型心绞痛患者或心肌梗死后患者的病历进行了前瞻性调查和回顾，这些患者被转诊接受PTCA（n = 1137）或CABG（n = 1226）。使用以下两组标准来衡量适宜性：（1）1991年由荷兰心脏病专家和心胸外科医生组成的专家小组制定的标准；（2）1998年由组成类似的欧洲专家小组制定的标准。
在慢性稳定型心绞痛患者（34.8%对6.1%；P < 0.001）和近期心肌梗死患者（28.1%对0.9%；P < 0.001）中，与跨国标准相比，荷兰标准将更多的PTCA转诊病例评为不适当。在接受搭桥手术的患者中，对于慢性稳定型心绞痛患者，荷兰标准判定不适当的病例比例高于跨国标准（3.7%对1.5%，P < 0.001）。两个专家小组对心肌梗死后患者中被评为不适合搭桥手术的病例比例相似（分别为3.9%对2.4%；P = 0.40）。在根据荷兰专家小组会议后出现的文献证据对适宜性标准中使用的两个临床因素（病变形态和药物治疗强度）的数据进行重新分类后，我们发现荷兰专家小组和跨国专家小组的适宜性评级之间没有显著差异。
虽然与荷兰标准相比，使用跨国标准判定为不适当的病例较少，但评级差异主要与每个专家小组使用的临床因素有关。这些发现支持对适宜性标准和其他形式的临床指南进行审查，以确保在使用它们评估临床护理之前与临床证据保持一致。与多个单一国家的专家小组相比，使用跨国专家小组制定此类标准将更有效地利用资源。
