Uso apropiado de la revascularización coronaria en España.

Appropriate use of coronary revascularization in Spain.

Title:

Appropriate use of coronary revascularization in Spain.

Background:

In Spain, as in other countries, there exists a high degree of variability in the use of coronary revascularization techniques, which are undergoing a rapid increase. These facts point to the possibility that a certain number of these coronary revascularization procedures are performed for inappropriate or questionable reasons.

Objectives:

This research project aims at gaining knowledge of the extent of appropriate, inappropriate and questionable use of coronary revascularization techniques, Percutaneous Transluminal Coronary Angioplasty (PTCA) and Coronary Revascularization Surgery (CRS) in Spain, as well as attempting to explore the possible variables which may explain inappropriate use. This information could be used to selectively promote the appropriate procedures. This method may also be applied to other technologies, and therefore the experience of this project may prove useful for other medical procedures.

The specific objectives of the project are:

1) To produce a summary of current knowledge of PTCA and CRS via a critical review of the literature.

2) To define standards for the performance of PTCA and CRS by classifying the specific clinical circumstances in which the use thereof is appropriate, inappropriate or questionable.

3) To measure the proportion of appropriate, inappropriate and questionable use of PTCA and CRS in Spain, on a national level and by different subgroups, in accordance with the previously defined standards.

4) To determine the strength of the association of inappropriate use with a number of variables of the center and patient.

5) To identify areas relative to the PTCA and CRS where no information exists and where it is insufficient or contradictory, and might be the subject of research in the future.

Methodology:

First phase: Application of the RAM Method (Rand Appropriateness Method) in the definition of standards for appropriate use.

The method involves the performance of a summary of scientific evidence, the preparation of a list of possible indications for coronary revascularization, the gathering together of a group of experts who allocate individual ratings with regard to the appropriateness of the performance of the intervention in each of the possible indications, performance of a modified delphi study in two rounds , the analysis of the degree of agreement and study of the ratings medians.

The summaries of the literature on PTCA and CRS have been carried out, together with a list of 1826 indications for coronary revascularization. These documents were used by the panel of experts which met in December of 1996 to allocate ratings to the list of indications. Based on the median rating allocated by the panel to each indication and the degree of agreement, each indication has been classified as either appropriate, questionable or inappropriate for PTCA and CRS. These Standards of Appropriate Use, together with a detailed description of the project methodology, have been published in the Revista Española de Cardiología (Lázaro P, Fitch K, Martín Y). Standards for the appropriate use of percutaneous transluminal coronary angioplasty and aortocoronary surgery. Rev Esp Cardiol 1998;51:689-715).

Second phase: Study of the extent of appropriate use of PTCAs and CRSs performed in Spain.

The field work has been completed, having analyzed the appropriate use of coronary revascularization in a sample of the hospitals in which such procedures are carried out.

Initially, a pilot study was performed in order to validate the form of data collection and the assistance manual in 8 units (4 of cardiovascular surgery and 4 of haemodynamics) in hospitals in Madrid. Having corrected the form in accordance with the pilot results, the collection of real data was performed from a sample of approximately 2000 case histories for each of the techniques (4000 histories in total). These histories have been obtained from 16 hospitals in the case of PTCA and from 16 in the case of CRS. The hospitals have been ranked in terms of number of annual interventions performed (low, average and high) and in terms of functional dependency (public or private).

Participants, in addition to the Scientific Department of the Kovacs Foundation:

Research Unit of Health Care Services, of the Carlos III Institute of the Spanish Ministry of Health, Spanish Cardiology Society, Spanish Society for Cardiovascular Surgery.

Co-financed by the Health Care Research Fund, from the Spanish Ministry of Health, the Spanish Heart Foundation, General Electric Medical Systems and Philips Medical Systems., ODDS, and the Spanish Cardiology Association.

Status:

Definition of standards and field work have concluded. Initial analyses have been carried out and multivariate analyses of associations are under way.

The tasks which have been completed have generated the following publications and presentations at Conferences:

Fitch K, Lázaro P, Martín Y, Bernstein S, Kahan J. Physician Recommendations for Coronary Revascularization: Variations by Clinical Specialty. Eur J Pub Helth (in press).

Aguilar MD, Lázaro P, Fitch K, Silva D. A strategy designed to reduce the unnecessary use of coronary revascularization in Spain. In: XIX Jornadas de Economía de la Salud ( Symposium on Health Economics). Spanish Association of Health Economics. Zaragoza, 1999: 623-635.

Lázaro P, Fitch K, Martín Y. Standards for the appropriate use of percutaneous transluminal coronary angioplasty and aortocoronary surgery. Rev Esp Cardiol 1998;51:689-715.

Lázaro P. Outcomes research and appropriateness of medical technologies. In: the place of outcomes research in health technology assessment. Panel sessions. Barcelona, International Society for Technology Assessment in Helath Care, 1997:147-156.

Inglada L, Rodríguez Artalejo F, García-Díaz JD, Lázaro P, Fitch K. Percutaneous transluminal coronary angioplasty (PTCA): review of the literature on effectiveness and risks. Madrid: Research Unit in Health Services, Carlos III Institute, 1996.

García-Díaz JD, Rodríguez Artalejo F, Inglada L, Lázaro P, Fitch K. Aortocoronary surgery with graft (ASG): review of the literature with regard to effectiveness and risks. Madrid: Research Unit in Health Services, Carlos III Institute, 1996.

Aguilar MD, Lázaro P, Fitch K, Silva D. Gender Differences in Asymptomatic Patients Undergoing Coronary Revascularization in Spain: Gender Bias or Difference in Pain Threshold? Proceedings of the International Society of Technology Assessment in Health Care (ISTAHC) 15th Annual Meeting. Edinburgh, UK, 20-23 June 1999.

Lázaro P, Aguilar MD, Fitch K, Silva D, Gobbo M. Variables Associated with Inappropriate Revascularization Procedures in Spain. Proceedings of the International Society of Technology Assessment in Health Care (ISTAHC) 15th Annual Meeting. Edinburgh, UK, 20-23 June 1999.

Fitch K, Lázaro P, Martín Y. Measuring and correcting internal inconsistencies in rating appropriateness of coronary revascularization procedures. Proceedings of the International Society of Technology Assessment in Health Care (ISTAHC) 14th Annual Meeting. Ottawa, 7-10 June 1998.

Lázaro P, Fitch K, Martín Y, Bernstein S. Physician recommendations for coronary revascularization: Variations by clinical specialty. Proceedings of the International Society of Technology Assessment in Health Care (ISTAHC) 14th Annual Meeting. Ottawa, 7-10 June 1998.

Lázaro P. Appropriate Use of coronary revascularization procedures. Workshop on "Methods of appropriate use of welfare resources". XIII Symposium of Public Health Care and Health Care Administration. Andalusian School of Public Health. Granada, 21/05/1998.

Fitch K, Lázaro P, Azcona B, Martín Y, Bernstein S, Kahan J. Applying the appropriateness method to improve quality of care: Coronary Revascularization procedures. In: 13th Annual Meeting of International Society for Technology Assessment in Health Care. Abstracts book. Barcelona, 1997: 155.

Lázaro P, Fitch K, Azcona B, Martín Y, Kahan J, Bernstein S. Assessing necessity: the need for simpler tools. The case of coronary revascularization procedures. In: 13th Annual Meeting of International Society for Technology Assessment in Health Care. Abstracts book. Barcelona, 1997: 113.