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Concordance of Physician Ratings With the Appropriate Use Criteria for Coronary Revascularization
Study Questions:
What is the consistency in appropriate use criteria (AUC) ratings for percutaneous coronary intervention (PCI) among a large unselected group of practicing cardiologists and the AUC Technical Panel?
Methods:
The authors surveyed 85 cardiologists from 10 US institutions and asked them to rate the appropriateness of coronary revascularization for 68 indications that had been evaluated by the AUC Technical Panel. Each indication was classified as appropriate, uncertain, or inappropriate, based on the physician group’s median rating. Rates of concordance between the physician group and the AUC Technical Panel and rates of nonagreement within the physician group were determined. Nonagreement was defined as ≥25% of panelists’ ratings outside the group’s appropriateness category assessment.
Results:
Overall concordance between the two groups was 84%, with highest concordance (94%, 34 of 36) for indications rated as appropriate by the AUC Technical Panel. Nonagreement between the physician group was high (16 of 36). Concordance was 73% for indications rated as uncertain and 70% for inappropriate indications. There was substantial variation in appropriateness ratings between individual physicians and the AUC Technical Panel (weighted κ range, 0.05-0.76).
Conclusions:
There was good overall concordance in assessments of appropriateness for coronary revascularization between physicians and the AUC Technical Panel, although nonagreement within the physician group was common, and there was marked variation in ratings between individual physicians and the AUC Technical Panel.
Perspective:
AUC for PCI are heavily based on expert consensus, and only a small subset of PCI indications has supporting randomized data. Since a large number of PCI indications fall in the uncertain category, it is not surprising that there is considerable disagreement among practicing physicians on the appropriateness of PCI for these indications. While some degree of disagreement is to be expected, institutions that diverge consistently and markedly from national benchmarks should consider focused reviews of their practice patterns to ensure that patients are being treated as per generally accepted guidelines, while recognizing that PCI will be totally appropriate for some patients, even though the indication may be ranked as inappropriate by the AUC.
Keywords: Uncertainty, Cardiology, Data Collection, Percutaneous Coronary Intervention
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