Physician recommendations for coronary revascularization. Variations by clinical speciality

Background: Studies have shown that clinical speciality has a strong influence on appropriateness ratings. We examined the effect of clinical speciality on physician recommendations for the performance of coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angloplasty (PTCA) in Spain. Methods: Following the RAND appropriateness method, a 10-member multispeciality panel composed of cardiovascular surgeons (CVs), interventional cardiologists (ICs), and non-interventional cardiologists (NICs) rated the appropriateness of 1826 hypothetical indications: 936 for coronary revascularization and 890 for preference between PTCA and CABG. For all revascularization indications and for all PTCA-CABG indications for which revascularization was rated appropriate by the panel, we calculated the mean appropriateness rating, by panellist and by speciality group, and the proportion of indications rated with preference for PTCA, with preference for CABG, and with no preference, by speciality group. Results: The ICs had a higher mean rating across all revascularization indications (7.8) than either the NICs (5.7) or the CVs (5.9). For the 509 indications rated appropriate for revascularization by the panel, the ICs preferred PTCA in 54% of indications, versus 39% for the NICs and 25% for the CVs. The CVs preferred CABG In 58% of indications, versus 32% for the NICs and 20% for the ICs. Conclusions: Appropriateness ratings varied by clinical speciality. Physicians who perform a procedure may be more aggressive in recommending its use than non-performers. Appropriateness panels should be multidisciplinary to accurately reflect the judgements of the different types of physicians involved in patient care.