OBJECTIVE: To devise a clinical prioritisation system for rationing access to a cardiac catheter waiting list and to describe its performance at predicting angiographic findings and selecting patients for angioplasty or coronary artery bypass graft surgery. SETTING: Tertiary level cardiology centre. METHODS: (1) 665 consecutive patients on an elective waiting list for coronary angiography were scored using a system derived from established clinical criteria for selecting patients for coronary surgery (New Zealand/Duke). The scores were compared with clinical outcome (referral for surgery, angioplasty, or medical management). (2) In a subset of 125 patients, scores derived from clinical criteria and exercise testing were compared with findings on coronary angiography. (3) Multivariate analysis was used in a new group of 178 patients to identify factors that would be better predictors of the angiographic score. (4) A new scoring system was devised based partly on the results of the multivariate analysis. It was applied to a new test group of 100 patients using clinical outcome and angiographic score as outcome measures. RESULTS: (1) Using the established clinical score, similar proportions of patients were referred after angiography for medical management, angioplasty, or coronary bypass grafting, irrespective of their original score. The exceptions were patients with a score < 20, who were more likely to continue medical management. (2) There was poor correlation (r = 0.05) between the clinical score and the subsequent angiographic score. (3) Multivariate analysis identified age, male sex, previous myocardial infarction, high cholesterol, and diabetes as independent predictors of coronary score. (4) The modified scoring system, incorporating the predictors identified by multivariate analysis, performed better than the original scoring system in predicting coronary score when both were tested, but some patients had severe disease despite a low score. CONCLUSIONS: Patients can be ranked using clinical and non-invasive criteria, and a rationing system implemented on this basis. With prioritisation by noninvasive criteria, the risk of missing serious coronary disease in patients with relatively mild symptoms must be accepted; this risk becomes greater the more stringently rationing is applied.
OBJECTIVE: To devise a clinical prioritisation system for rationing access to a cardiac catheter waiting list and to describe its performance at predicting angiographic findings and selecting patients for angioplasty or coronary artery bypass graft surgery. SETTING: Tertiary level cardiology centre. METHODS: (1) 665 consecutive patients on an elective waiting list for coronary angiography were scored using a system derived from established clinical criteria for selecting patients for coronary surgery (New Zealand/Duke). The scores were compared with clinical outcome (referral for surgery, angioplasty, or medical management). (2) In a subset of 125 patients, scores derived from clinical criteria and exercise testing were compared with findings on coronary angiography. (3) Multivariate analysis was used in a new group of 178 patients to identify factors that would be better predictors of the angiographic score. (4) A new scoring system was devised based partly on the results of the multivariate analysis. It was applied to a new test group of 100 patients using clinical outcome and angiographic score as outcome measures. RESULTS: (1) Using the established clinical score, similar proportions of patients were referred after angiography for medical management, angioplasty, or coronary bypass grafting, irrespective of their original score. The exceptions were patients with a score < 20, who were more likely to continue medical management. (2) There was poor correlation (r = 0.05) between the clinical score and the subsequent angiographic score. (3) Multivariate analysis identified age, male sex, previous myocardial infarction, high cholesterol, and diabetes as independent predictors of coronary score. (4) The modified scoring system, incorporating the predictors identified by multivariate analysis, performed better than the original scoring system in predicting coronary score when both were tested, but some patients had severe disease despite a low score. CONCLUSIONS:Patients can be ranked using clinical and non-invasive criteria, and a rationing system implemented on this basis. With prioritisation by noninvasive criteria, the risk of missing serious coronary disease in patients with relatively mild symptoms must be accepted; this risk becomes greater the more stringently rationing is applied.
Authors: D B Mark; C L Nelson; R M Califf; F E Harrell; K L Lee; R H Jones; D F Fortin; R S Stack; D D Glower; L R Smith Journal: Circulation Date: 1994-05 Impact factor: 29.690