APPROPRIATE USE OF CORONARY REVASCULARIZATION
IN SPAIN
Title.
Appropriate use of coronary revascularization
in Spain.
Background.
In Spain, as in other countries, there is
great variability in the use of techniques of coronary revascularization;
furthermore, these techniques are growing rapidly. These facts
suggest the possibility that some proportion of the procedures
for coronary revascularization is made inappropriately or
for dubious reasons. Studying this possibility would permit
a selective promotion of only the appropriate procedures.
This method can also be applied to other technologies, so
that the experience of this project could be useful for other
medical procedures.
Objectives.
To find out the degree of appropriate, inappropriate
and uncertain use of techniques of coronary revascularization,
Percutaneous Transluminal Coronary Angioplasty (PTCA) and
Coronary Revascularization Surgery (CRS) in Spain, as well
as to try to explore possible explanatory variables of their
inappropriate use.
The specific objectives of the project are:
- To produce a synthesis of current
knowledge about PTCA and CRS by means of a critical review
of the literature.
- To prepare standards for carrying
out PTCA and CRS, classifying the specific clinical circumstances
in which their use is appropriate, inappropriate and uncertain.
- To measure the proportion of appropriate,
inappropriate and uncertain use of PTCA and CRS in Spain,
on a national level and by different subgroups in accordance
with the previously elaborated standards.
- To determine the strength of association
of inappropriate use with a series of variables concerning
the center and the patient.
- To identify areas relative to PTCA
and CRS in which there is no information and where the information
is insufficient or contradictory, for which future research
is necessary.
Methodology.
First Phase: Application of the RAM Method
(Rand Appropriateness Method) to produce standards of appropriate
use.
The method entails synthesizing scientific
evidence, elaborating the list of possible indications for
coronary revascularization, bringing together a group of
experts that rate individually the appropriateness of an
intervention in each one of the possible indications, making
a modified Delphi to two rounds, to assess the degree of
concordance and to analyze the averages of the scores.The
review and synthesis of literature on PCTA and CRS, along
with a list of 1826 indications for coronary revascularization,
has been made. These documents were used by the panel of
experts that met in December 1996 to score the list of indications.
Based on the average scores of the panel for each indication
and the level of agreement, each indication has been classified
as appropriate, uncertain or inappropriate for PTCA or CRS.
These standards of appropriate use, along with a detailed
description of the project's methodology have been published
in the Revista Española de Cardiología (Spanish
Cardiology Review) (Lázaro P, Fitch K, Martín
Y. Estándares para el uso apropiado de la angioplastia
coronaria transluminal percutánea y cirugía
aorto-coronaria. Rev Esp Cardiol 1998;51:689-715).
Second phase: Study of the degree of appropriate
use of PTCA's and CRS's performed in Spain.
The fieldwork, in which the appropriate
use of coronary revascularization is studied in a sample
of hospitals where these procedures are performed, has been
completed. First a pilot test was carried out to validate
the form for data collecting and the aid manual in 8 services
(4 of cardiovascular surgery and 4 of homodynamic) in hospitals
in Madrid. Once the form was corrected according to the
pilot results, the collection of real data was begun in
a sampling of approximately 2,000 clinical histories for
each one of the techniques (4,000 histories in all). These
histories have been obtained from 16 hospitals in the case
of PTCA and 16 in the case of CRS. The hospitals have been
stratified according to the volume of interventions performed
annually (low, medium and high) and according to their operating
status (public or private).
Participants, along with the Science Department
of the Kovacs Foundation.
Unit of Research in Health Services at the
Carlos III Institute of the Spanish Ministry of Health and
Consumer Services, Spanish Cardiology Society, and Spanish
Society of Cardiovascular Surgery.
Co-funded by the Fund for Health Research of the Spanish
Ministry of Health and Consumer Services, the Spanish Heart
Foundation, General Electric Medical Systems, Philips Medical
Systems, ODDS and the Spanish Cardiology Society.
Status.
The work already completed has given rise
to the following publications and presentations in congresses:
Eur J Pub Health 1999;9:181-187.
Int J Cardiol 2001 May; 78(3): 213-21; discussion 221-3.
Informática y Salud 2000;24:28.
Monografies mediques de l'Academia de Ciencies Mediques
de Catalunya i de Baleares. Barcelona 1999;185-200.
International Proceedings Division. Bologna 1999:41-47.
XIX Jornadas de Economía de la Salud. Zaragoza,
1999: 431-432.
XIX Jornadas de Economía de la Salud. Asociación
de Economía de la Salud. Zaragoza, 1999: 623-635.
Rev Esp Cardiol 1998;51:689-715.
Panels sessions. Barcelona, International Society for Technology
Assessment in Health Care, 1997:147-156.
Madrid: Unidad de Investigación en Servicios de
Salud, Instituto de Salud Carlos III, 1996.
Madrid: Unidad de Investigación en Servicios de
Salud, Instituto de Salud Carlos III, 1996.
Proceedings of the International Society of Technology
Assessment in Health Care (ISTAHC) 15th Annual Meeting.
Edinburgh, UK, 20-23 June 1999.
Proceedings of the International Society of Technology
Assessment in Health Care (ISTAHC) 15th Annual Meeting.
Edinburgh, UK, 20-23 June 1999.
Proceedings of the International Society of Technology
Assessment in Health Care (ISTAHC) 14th Annual Meeting.
Ottawa, 7-10 June 1998.
Physician recommendations for coronary of Technology Assessment
in Health Care (ISTAHC) 14th Annual Meeting, Ottawa, 7-10
June 1998.
XIII Jornadas de Salud Pública y Administración
Sanitaria. Escuela Andaluza de Salud Pública. Granada,
21/05/1998.
13 Annual Meeting of the International Society for Technology
Assessment in Health Care. Abstracts book. Barcelona, 1997:155.
13 Annual Meeting of the International Society for Technology
Assessment in Health Care. Abstracts book. Barcelona, 1997:113.
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