The European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE): project and methods

The carbon cost of inappropriate endoscopy

BACKGROUND AND AIMS

Digestive endoscopy is a resource-intensive activity with a conspicuous carbon footprint and an estimated rate of inappropriateness. However, the carbon costs of inappropriate endoscopic procedures still remain obscure. Here we evaluated the environmental impact of inappropriate endoscopic examinations.

METHODS

We calculated the carbon cost of a standard endoscopic procedure (EGD and colonoscopy [CLS]), taking into account the items (eg, disposable materials, personal protective equipment) and energy required for the endoscopy procedure itself and the cleaning process. The rates of inappropriateness and the mortality cost of carbon (MCC) of endoscopic examinations in different scenarios were calculated.

RESULTS

EGD and CLS presented a carbon cost of 5.43 kg and 6.71 kg of CO2, respectively. Different scenarios were evaluated, according to the number of endoscopic procedures performed in Italy per 1000 inhabitants and the reported data on their inappropriateness. The carbon cost of inappropriate EGD and CLS in Italy was 4133 CO2 metric tons per year (MCC, .93), ranging from 3527 to 4749, and equivalent to 1,760,446 L of gasoline consumed. Applying the same data to the European population, the estimated carbon footprint of inappropriate digestive endoscopy in Europe was 30,804 metric tons.

CONCLUSIONS

The environmental impact of inappropriate endoscopic procedures in Europe is remarkable. These results highlight the need to adopt novel strategies aimed at reducing both the carbon footprint of digestive endoscopy and the rate of inappropriate procedures.

Systematic Review of Pharmacogenetic Factors That Influence High-Dose Methotrexate Pharmacokinetics in Pediatric Malignancies

Methotrexate (MTX) is a mainstay therapeutic agent administered at high doses for the treatment of pediatric and adult malignancies, such as acute lymphoblastic leukemia, osteosarcoma, and lymphoma. Despite the vast evidence for clinical efficacy, high-dose MTX displays significant inter-individual pharmacokinetic variability. Delayed MTX clearance can lead to prolonged, elevated exposure, causing increased risks for nephrotoxicity, mucositis, seizures, and neutropenia. Numerous pharmacogenetic studies have investigated the effects of several genes and polymorphisms on MTX clearance in an attempt to better understand the pharmacokinetic variability and improve patient outcomes. To date, several genes and polymorphisms that affect MTX clearance have been identified. However, evidence for select genes have conflicting results or lack the necessary replication and validation needed to confirm their effects on MTX clearance. Therefore, we performed a systematic review to identify and then summarize the pharmacogenetic factors that influence high-dose MTX pharmacokinetics in pediatric malignancies. Using the PRISMA guidelines, we analyzed 58 articles and 24 different genes that were associated with transporter pharmacology or the folate transport pathway. We conclude that there is only one gene that reliably demonstrates an effect on MTX pharmacokinetics: SLCO1B1.

Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams

BACKGROUND

Colonoscopy is frequently performed in industrialised countries. Inappropriate colonoscopies might lead to unnecessary exams, increasing risks and costs.

AIM

To estimate the impact of colonoscopy appropriateness in terms of gain in additional diagnoses and sparing of unnecessary exams.

METHODS

Systematic review including studies reporting the prevalence of relevant findings, colorectal cancer (CRC) and inflammatory bowel disease (IBD) according to colonoscopy appropriateness as defined by the American Society for Gastrointestinal Endoscopy and European Panel on Appropriateness of Gastrointestinal Endoscopy.

RESULTS

Twenty-one studies with 19,822 patients were included. Colonoscopy was appropriate in 15,162 (71%, CI 64%-78%). Appropriateness significantly increased the probability of relevant findings (34% vs. 18%; RR 1.81, CI 1.53-2.14), CRC (7% vs. 2%; RR 3.62, CI 2.44-5.37) and IBD (6% vs. 4%; RR 1.86, CI 1.09-3.19). Appropriateness had sensitivity 88% (CI 85%-91%), 97% (CI 93%-98%) and 89% (CI 80%-94%), and specificity 24% (CI 20%-29%), 22% (CI 18%-26%) and 24% (CI 20%-28%) for relevant findings, CRC and IBD, respectively. On average, performing colonoscopy with appropriate indication would find 15 (CI 10-21) more relevant findings, five (CI 3-9) more CRCs and three (CI 1-9) more diagnoses of IBD per 100 patients, and save 24 (CI 20-29), 22 (CI 18-26) and 24 (CI 20-28) examinations per 100 patients for relevant findings, CRC and IBD, respectively.

CONCLUSIONS

Appropriateness affects the diagnostic yield of colonoscopy for CRC, IBD and relevant findings. Appropriateness criteria are useful, although integrated with clinical evaluation of the patient.

The impact of covid-19 pandemic on urgent endoscopy in Italy: a nation-wide multicenter study

Objective: COVID-19 pandemic has seriously affected Italy. Radical changes occurred in the Italian NHS and thus in GI departments, as only urgent endoscopies were guaranteed. The study aimed to report how the demand for urgent endoscopy changed during the COVID-19 pandemic in Italy and to evaluate the appropriateness of urgent referrals in the Endoscopy Unit.Material and methods: Nation-wide, cross-sectional survey study in 54 Italian GI Units. Data were collected regarding urgent endoscopies (EGD, CS, ERCP) in two different time periods: March 2019 and March 2020.Results: Thirty-five (64.8%) GI endoscopy Units responded to the survey. The entity of reduction of overall urgent EGDs and CSs performed in March 2020 versus March 2019 was statistically significant: 541 versus 974 (-80%), p < .001 for EGD and 171 versus 265 (-55%), p < .008, for CS, respectively. No statistically significant reduction of urgent ERCP performed in March 2020 versus March 2019 was found. The increase in overall diagnostic yield for urgent EGD in March 2020 versus March 2019 was 7.3% (CI [0.028-0.117], p = .001). No statistically significant difference in diagnostic yield for CS between 2019 and 2020 was found.Conclusion: The study showed a statistically significant reduction of urgent EGD and CS performed during the SARS-CoV-2 pandemic, in March 2020, compared to March 2019. The diagnostic yield of urgent EGD performed in March 2020 was significantly higher than that of March 2019. No statistically significant difference was found in terms of diagnostic yield of urgent CS between March 2020 and March 2019.

Diagnostic yield of upper endoscopy according to appropriateness: A systematic review

BACKGROUND/AIM

Despite some official guidelines are available, a substantial rate of inappropriateness for upper gastrointestinal (UGI) endoscopies has been reported. This study aimed to estimate the inappropriate rate of UGI in different countries, also including the diagnostic yield.

METHODS

A systematic review of studies on UGI endoscopy appropriateness was performed by adopting official guidelines as reference standard. Diagnostic yield of relevant endoscopic findings and cancers was compared between appropriate and inappropriate procedures. The Odd Ratio (OR) values and the Number-Needed-to-Scope (NNS) were calculated.

RESULTS

Data of 23 studies with a total of 53,392 patients were included. UGI indications were overall inappropriate in 21.7% (95% CI = 21.4-22.1) of the patients. The inappropriateness rate significantly (P < 0.0001) decreased from 35.1% in the earlier studies to 22.1%-23% in the more recent ones. A relevant finding was found in 43.3% of appropriate and in 35.1% of inappropriate endoscopies (P < 0.0001; OR: 1.42, 95% CI = 1.36-1.49; NNS = 12). Prevalence of cancers was also higher in appropriate than in inappropriate UGIs (2.98% vs. 0.09%, P < 0.0001; OR = 3.33; NNS = 48). The prevalence of detected cancers significantly (P < 0.004) increased from 1.38% in the earlier studies to 2.11% in the more recent ones, whilst prevalence of other relevant findings remained similar.

CONCLUSIONS

Rate of inappropriate UGI endoscopies is still high. Diagnostic yield of appropriate endoscopies is higher than that of inappropriate procedures, including upper GI cancers. Therefore, implementation of guidelines in clinical practice is urged.

Comparative analysis of diagnostic colonoscopy in symptomatic young adults from South Korea and the United States

To date, not much is known about ethnic differences in the prevalence of colorectal neoplasia in symptomatic young patients with lower gastrointestinal symptoms. This study sought to compare diagnostic colonoscopic findings in symptomatic young patients from South Korea and the United States. Results from the first diagnostic colonoscopies in symptomatic 18- to 49-year-old patients were compared between the United States and Korean cohorts. The US cohort data were collected at Virginia Mason Medical Center in Seattle, Washington between January 2007 and January 2010, and the Korean cohort data were collected at 14 university hospitals in Korea between June 2006 and June 2015.The prevalence of advanced neoplasias was similar in both cohorts for bleeding and nonbleeding symptoms (P = .966 and P = .076, respectively). In a subgroup analysis for 40- to 49-year-old patients, the prevalence of advanced neoplasias was similar for bleeding symptoms; however, nonbleeding symptoms were significantly higher in the Korean cohort than in the US cohort (6.2% vs 2.6%, P < .001). In an age subgroup analysis for 18- to 39-year-old patients, the prevalence of advanced neoplasias was similar for bleeding and nonbleeding symptoms in both cohorts. Multivariate analysis showed that lower gastrointestinal symptoms were not associated with the risk of any type of advanced neoplasia in young Korean patients.Ethnic disparities in the prevalence of advanced neoplasia on diagnostic colonoscopy were not noticeable between Korean and US young patients. However, 40- to 49-year-old patients with nonbleeding symptoms require more attention to detect advanced neoplasia in Korea than similarly aged patients in the United States.

Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category

BACKGROUND

The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms.

OBJECTIVE

To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort).

DESIGN

Retrospective controlled cohort study.

SETTING

Teaching hospital.

PATIENTS

Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years.

INTERVENTIONS

Colonoscopy.

MAIN OUTCOME MEASUREMENTS

Prevalence of advanced neoplasia.

RESULTS

During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neoplasia in patients with rectal bleeding was comparable with that in the screening controls: 28 of 472 (5.9%) versus 113 of 1638 patients (6.9%) (P = .459). Furthermore, 10 patients (2.1%) with rectal bleeding were newly diagnosed with inflammatory bowel disease. In contrast, other symptoms that commonly lead to colonoscopy, such as abdominal pain, changes in bowel habits, and weight loss, were associated with much lower risks for neoplasia. As a result, the overall prevalences of neoplasia and advanced neoplasia were significantly higher in the screening cohort than in the diagnostic cohort: 467 of 1638 patients (28.5%) versus 179 of 1266 patients (14.1%), and 113 patients (6.9%) versus 48 patients (3.8%), respectively (both P < .001).

LIMITATIONS

No data on duration of symptoms; discrepant sex ratios between cohorts.

CONCLUSION

The threshold for diagnostic colonoscopy in symptomatic young adults should be individualized for each symptom category. Rectal bleeding warrants colonoscopy to detect advanced neoplasia or inflammatory bowel disease in most young patients, especially those aged 40 to 49 years, whereas non-bleeding symptoms, including some traditionally regarded as "alarm" symptoms, were associated with a much lower risk for neoplasia compared with the risk in screening patients aged 50 to 54 years.

European panel on the appropriateness of gastrointestinal endoscopy II guidelines help in selecting and prioritizing patients referred to colonoscopy--a quality control study

OBJECTIVE

To use information from the referral letters to assess the appropriateness of colonoscopies in a primary open-access referral center, according to the criteria from the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II, and to compare with the first EPAGE guidelines. Second, to evaluate how the appropriateness and other patient- or doctor-related factors affected the diagnostic yield (DY).

MATERIAL AND METHODS

A set of variables; symptoms, referring physician and final diagnosis, for 323 referrals accepted for colonoscopy were recorded prospectively and later on assessed using the EPAGE and EPAGE II criteria, respectively. Patients with incomplete visualization of the entire colon or colonoscopic findings as indication were excluded.

RESULTS

EPAGE and EPAGE II criteria were applicable in 287 (95.3%) and 295 (98.0%) referrals, respectively. A total of 166 (57.8%) patients were considered appropriate by EPAGE and 240 (81.4%) patients were considered appropriate by EPAGE II. DY for appropriate versus uncertain/inappropriate referrals was 34.9% versus 17.4% for EPAGE (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.8-4.4, p = 0.003) and 31.3% versus 10.9% for EPAGE II (OR = 3.5, 95% CI: 1.4-8.9, p = 0.007). Sensitivity was higher for EPAGE II (92.6% vs. 73.4%). According to EPAGE II, 68 (23.1%) patients were referred due to lesions identified on other diagnostic procedures, producing a DY of 39.7%. In this group, 70% presented symptoms appropriate for a primary referral to colonoscopy.

CONCLUSIONS

The majority of colonoscopies were found appropriate by EPAGE II. There was a clear association between high appropriateness of the indication and a high DY. EPAGE II is a guideline-improvement that may be useful for both referring physicians and gastroenterologists when considering referrals.

Diagnostic yield of endoscopy in patients with abdominal complaints: incremental value of faecal calprotectin on guidelines of appropriateness

BACKGROUND

European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria have been developed to increase diagnostic yield, but their predictive value is limited. We investigated the incremental diagnostic value of faecal calprotectin to EPAGE criteria.

METHODS

In a post-hoc analysis of a prospective study, EPAGE criteria were applied to 298 of 575 (51.8%) patients who had undergone esophagogastroduodenoscopy (EGD), colonoscopy or both for abdominal complaints at the Division of Gastroenterology & Hepatology at the University Hospital Basel in Switzerland. Faecal calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. Final endoscopic diagnoses were blinded to calprotectin values.

RESULTS

Of 149 EGDs and 224 colonoscopies, 17.6% and 14.7% respectively were judged inappropriate by EPAGE criteria. Appropriate or uncertain indications revealed more endoscopic findings in both EGD (46.3% vs. 23.1%, P = 0.049) and colonoscopy (23.6% vs. 6.1%, P = 0.041) than inappropriate indications. Median calprotectin levels were higher (81.5 μg/g, interquartile range 26-175, vs. 10 μg/g, IQR 10-22, P < 0.001) and testing was more often positive (>50 μg/g) in patients with endoscopic findings, both in EGD (58.2% vs. 33.0%, P = 0.005) and in colonoscopy (57.3% vs. 7.4%, P < 0.001). The use of faecal calprotectin in addition to EPAGE criteria improved the risk reclassification of patients by endoscopic findings. The calculated net reclassification index was 37.8% (P = 0.002) for EGD and 110.9% (P <0.001) for colonoscopy, thus improving diagnostic yield to 56.8% and 70.2%, respectively.

CONCLUSIONS

The use of faecal calprotectin in addition to EPAGE criteria improved diagnostic yield in patients with abdominal complaints.

Value of fecal calprotectin in the evaluation of patients with abdominal discomfort: an observational study

Background

The evaluation of patients with abdominal discomfort is challenging and patient selection for endoscopy based on symptoms is not reliable. We evaluated the diagnostic value of fecal calprotectin in patients with abdominal discomfort.

Methods

In an observational study, 575 consecutive patients with abdominal discomfort referred for endoscopy to the Department of Gastroenterology & Hepatology at the University Hospital Basel in Switzerland, were enrolled in the study. Calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. The presence of a clinically significant finding in the gastrointestinal tract was the primary endpoint of the study. Final diagnoses were adjudicated blinded to calprotectin values.

Results

Median calprotectin levels were higher in patients with significant findings (N = 212, median 97 μg/g, IQR 43-185) than in patients without (N = 326, 10 μg/g, IQR 10-23, P < 0.001). The area under the receiver operating characteristics curve (AUC) to identify a significant finding was 0.877 (95% CI, 0.85-0.90). Using 50 μg/g as cut off yielded a sensitivity of 73% and a specificity of 93% with good positive and negative likelihood ratios (10.8 and 0.29, respectively). Fecal calprotectin was useful as a diagnostic parameter both for findings in the upper intestinal tract (AUC 0.730, 0.66-0.79) and for the colon (AUC 0.912, 0.88-0.94) with higher diagnostic precision for the latter (P < 0.001). In patients > 50 years, the diagnostic precision remained unchanged (AUC 0.889 vs. 0.832, P = 0.165).

Conclusion

In patients with abdominal discomfort, fecal calprotectin is a useful non-invasive marker to identify clinically significant findings of the gastrointestinal tract, irrespective of age.

The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria

BACKGROUND

The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care.

OBJECTIVES

To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria.

DESIGN

Cross-sectional study.

SETTING

Endoscopy unit of a teaching hospital in Spain.

PATIENTS

Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing.

MAIN OUTCOME MEASUREMENTS

Appropriateness of colonoscopies according to the EPAGE criteria.

RESULTS

From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer-related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels.

LIMITATIONS

The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria.

CONCLUSIONS

Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.

[Management of open access gastrointestinal endoscopy and quality of care: collaboration between an improvement team and primary care]

OBJECTIVE

To create an improvement team within a healthcare quality improvement project of the Government of Aragon (Spain), aimed at increasing the quality of care and suitability of the indications of gastrointestinal endoscopy in the open access endoscopy system of a secondary hospital in Aragon.

DESIGN

The team developed a consensus document indicating how to use oral endoscopy and colonoscopy correctly, and held information and training sessions with all the primary care physicians involved in this area.

LOCATION

Sector I health centers and Royo Villanova Hospital, in Zaragoza.

PARTICIPANTS

The team consisted of a gastroenterologist and three primary care physicians and, from the outset received the support of the primary care administration and management in the health area.

RESULTS

Inappropriate use of endoscopy, particularly colonoscopy, was reduced from 20% to 11.6%. Significant savings were achieved in health costs. The endoscopy waiting list was reduced. The quality of care and the safety of patients undergoing these examinations improved. Training of primary care physicians in these procedures was enhanced, and coordination between primary and specialized was implemented.

CONCLUSIONS

To ensure efficient running of an open access gastrointestinal endoscopy system, an interdisciplinary improvement team and the full involvement of the primary care staff managing this resource are required.

[Evidence-based radiology for diagnostic imaging: what it is and how to practice it]

Evidence-based radiology is defined as the decision that results from integrating clinical information to select the most appropriate imaging test on the basis of the best available evidence, the physician's experience, and the patient's expectations. The practice of evidence-based radiology consists of five steps: formulating the question, performing an efficient search of the literature, critically evaluating the literature, applying the results of the search and evaluation while taking into account our experience and the patient's values, and evaluating the results obtained within our own practice. In diagnostic imaging, the number of resources available for evidence-based radiology is increasing: apart from books, articles, and web pages on this subject, evidence-based radiology is receiving more attention at diagnostic imaging conferences. The principles of evidence-based radiology will help promote the appropriate use of resources, greatly benefiting patients (decreasing the use of examinations that use ionizing radiation), professionals (less overload), and managers (more efficient use of resources).

Infliximab for Crohn's disease in the Swiss IBD Cohort Study: clinical management and appropriateness

OBJECTIVE

Antitumor necrosis factor a agents have significantly improved the management of Crohn's disease (CD), but not all patients benefit from this therapy. We used data from the Swiss Inflammatory Bowel Disease Cohort Study and predefined appropriateness criteria to examine the appropriateness of use of infliximab (IFX) in CD patients.

METHODS

EPACT II (European Panel on the Appropriateness of CD Therapy, 2007; www.epact.ch) appropriateness criteria have been developed using a formal explicit panel process combining evidence from the published literature and expert opinion. Questionnaires relating to EPACT II criteria were used at enrollment and follow-up of all Swiss Inflammatory Bowel Disease Cohort Study patients. A step-by-step analysis of all possible indications for IFX therapy in a given patient allowed identification of the most appropriate indication and final classification in a single appropriateness category (appropriate, uncertain, inappropriate).

RESULTS

Eight hundred and twenty-one CD patients were prospectively enrolled between November 2006 and March 2009. IFX was administered to 146 patients (18%) at enrollment and was most frequently used for complex fistulizing disease and for the maintenance of remission induced by biological therapy. IFX therapy was considered appropriate in 44%, uncertain in 44%, and inappropriate in 10% of patients.

CONCLUSION

In this cohort, 9 out of 10 indications for IFX therapy were clinically generally acceptable (appropriate or uncertain) according to EPACT II criteria. Uncertain indications resulted mainly from the current more liberal use of IFX in clinical practice as compared with the EPACT II criteria.

Indications to upper gastrointestinal endoscopy in children with dyspepsia

OBJECTIVES

The objective of the study was to ascertain the appropriateness of indications for upper gastrointestinal (UGI) endoscopy in children with dyspepsia.

METHODS

We used the RAND/University of California at Los Angeles method to investigate the appropriateness of the opinions of a panel of experts. The panel judged 2304 theoretical patient scenarios defined by a combination of demographic and clinical variables. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

The panel rated UGI endoscopy as appropriate in 27.2% of cases, inappropriate in 14.3%, and dubious in 58.5%. Disagreement emerged for 21% of cases. UGI endoscopy was considered increasingly appropriate in cases with a positive family history of peptic ulcer and/or Helicobacter pylori infection (odds ratio [OR] 8.518, P < 0.0001), when dyspepsia interfered with activities of daily living ("sleep" OR 7.540, P < 0.0001; "normal activities" OR 5.725, P < 0.0001), and when patients were older than 10 years ("<or=10 years" OR 0.310, P < 0.0001) the longer the duration ("0-2 months" OR 0.002, P < 0.0001; "3-5 months" OR 0.059, P < 0.0001; "6-11 months" OR 0.516, P = 0.0005) and the greater the severity ("mild" OR 0.002, P < 0.0001; "moderate" OR 0.013, P < 0.0001) of their dyspeptic symptoms.

CONCLUSIONS

UGI endoscopy is not appropriate for all children with dyspeptic symptoms, but only for cases with a family history of peptic ulcer and/or Helicobacter pylori infection, older than 10 years of age, with symptoms persisting for more than 6 months and severe enough to affect activities of daily living.

The effect of nonmedical factors on variations in the performance of colonoscopy among different health care settings

BACKGROUND

Previous published studies have shown significant variations in colonoscopy performance, even when medical factors are taken into account. This study aimed to examine the role of nonmedical factors (ie, embodied in health care system design) as possible contributors to variations in colonoscopy performance.

METHODS

Patient data from a multicenter observational study conducted between 2000 and 2002 in 21 centers in 11 western countries were used. Variability was captured through 2 performance outcomes (diagnostic yield and colonoscopy withdrawal time), jointly studied as dependent variables, using a multilevel 2-equation system.

RESULTS

Results showed that open-access systems and high-volume colonoscopy centers were independently associated with a higher likelihood of detecting significant lesions and longer withdrawal durations. Fee for service (FFS) payment was associated with shorter withdrawal durations, and so had an indirect negative impact on the diagnostic yield. Teaching centers exhibited lower detection rates and longer withdrawal times.

CONCLUSIONS

Our results suggest that gatekeeping colonoscopy is likely to miss patients with significant lesions and that developing specialized colonoscopy units is important to improve performance. Results also suggest that FFS may result in a lower quality of care in colonoscopy practice and highlight the fact that longer withdrawal times do not necessarily indicate higher quality in teaching centers.

[Review of the utilization of the RAND appropriateness method in the biomedical literature (1999-2004)]

OBJECTIVES

To identify and describe studies using the RAND/UCLA method to evaluate the appropriateness of health procedures. This method is a consensus technique that involves several phases to develop appropriateness criteria.

METHODS

We performed a literature search in 2005. OVIDMedline, ISI Web of Knowledge, IME and Highwire were consulted. Articles published between 1999 and 2004 and using the key words "appropriateness", "utilization review" and "physician practice patterns" were selected. Studies using the RAND method were included and those that did not explain the methodology in sufficient detail were excluded. Information on the procedure studied, the place and year of publication, and the characteristics of the journal were extracted from each article.

RESULTS AND DISCUSSION

A total of 5092 articles were identified and 205 were selected. Slightly more than half analyzed surgical or medical procedures, while 16.5% evaluated healthcare quality. More than 50% were published in journals of public health, general medicine, and gastroenterology and hepatology. The mean impact factor was 4.07. A quarter (25.4%) of the articles was published in 1999. CONCLUSIONS AND PERSPECTIVE: The RAND method is still widely used. Appropriateness criteria can be used to review utilization of procedures, to design guidelines, or to support for decision making. These tools should be reviewed to obtain evermore valid and reliable results.

Is diagnostic and therapeutic endoscopy currently appropriate?: suggestions for improvement

Endoscopy is the driving force in gastroenterology today, and recent exciting advances in technology have extended its frontiers at an unprecedented rate. We have a wider range of diagnostic and therapeutic possibilities at our disposal with more detailed methods available to analyse what we see on our video screens. We can access the small bowel lumen with consistency and intra-abdominal operations have been performed through the mouth and anus so where are the current limitations of the procedure? In spite of these remarkable advances many challenges remain for both the endoscopist and for industry, they are mainly ones associated with human weakness. Endoscopy is an art, performed by individuals who require training and continued education and it is done to patients who are vulnerable, afraid and often seriously unwell. It is human aspects of endoscopy that require improvement. This chapter addresses the areas where endoscopy is falling short and suggests what can be done to improve practice. Changes are needed in management, information technology, education, team working, quality, patient comfort and safety. There also remain a number of areas where improved technology may be able to reduce human error.

Appropriateness of colonoscopy in the era of colorectal cancer screening: a prospective, multicenter study in a private-practice setting (Berlin Colonoscopy Project 1, BECOP 1)

PURPOSE

The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases.

METHODS

A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions).

RESULTS

During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent.

CONCLUSIONS

Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients.

Factors associated with the technical performance of colonoscopy: An EPAGE Study

BACKGROUND

Variations in colonoscopy practice exist, which may be related to healthcare quality.

AIMS

To determine factors associated with three performance indicators of colonoscopy: complete colonoscopy, adenomatous polyp diagnosis, and duration.

PATIENTS

Consecutive patients referred for colonoscopy from 21 centres in 11 countries.

METHODS

This prospective observational study used multiple variable regression analyses to identify determinants of the quality indicators.

RESULTS

Six thousand and four patients were included in the study. Patients from private, open-access centres (odds ratio: 3.17, 95% confidence interval: 1.87-5.38) were more likely to have a complete colonoscopy than patients from public, gatekeeper centres. Patients from centres where over 50% of the endoscopists were of senior rank were roughly twice as likely to have an adenoma diagnosed, and longer average withdrawal duration (odds ratio: 1.08, 95% confidence interval: 1.07-1.09) was associated with more frequent adenoma diagnoses. Patients who had difficulty during colonoscopy had longer durations to caecum (time ratio: 2.87, 95% confidence interval: 2.72-3.01) and withdrawal durations (time ratio: 1.26, 95% confidence interval: 1.18-1.33) than patients who had no difficulties.

CONCLUSIONS

Multiple factors have been identified as being associated with key quality indicators. The non-modifiable factors permit the identification of patients who may be at greater risk of not having quality colonoscopy, while changes to the modifiable factors may help improve the quality of colonoscopy.

Appropriateness of upper gastrointestinal endoscopy in children: a retrospective study

BACKGROUND

Upper gastrointestinal endoscopy (UGIE) is appropriate in many situations in adults and children. Recommendations for UGIE use in children were published recently by the French-language Paediatric Hepatology, Gastroenterology, and Nutrition Group (GFHGNP).

PATIENTS AND METHODS

We retrospectively reviewed the 293 UGIE procedures undertaken in 251 children between January 1, 2001 and June 30, 2003 by 2 senior endoscopists. The UGIE procedures were categorized as appropriate or inappropriate based on GFHGNP recommendations, and diagnostic efficiency was compared in the 2 groups with the chi2 test followed by multivariate logistic regression analysis.

RESULTS

Of the 293 UGIE procedures, 52 (17.7%) were considered inappropriate. Diagnostic efficiency was 51% in the appropriate group versus 17.3% in the inappropriate group (odds ratio, 4.2; 95% CI, 2-8.7; P < 10(-3)). The proportion of appropriate UGIE procedures was higher among inpatients than outpatients (odds ratio, 2.51; 95% CI, 1.24-5.08; P = 0.01). Inappropriate reasons for performing UGIE included isolated failure to thrive and follow-up after neonatal esophagogastroduodenitis. Nine inappropriate UGIE procedures contributed useful information: ulcerative esophagitis in 1 patient, hemorrhagic esophagitis in 4 patients, duodenitis in 1 patient, and malabsorption in 3 patients caused in 1 case by cow's milk allergy and in 2 cases to fully documented celiac disease.

CONCLUSIONS

UGIE was usually performed appropriately in our pediatric hospital. Inappropriate UGIE procedures were more common in outpatients than in admitted patients. Awareness of the recommendations for appropriate UGIE use needs to be improved among office-based and hospital-based physicians.

The appropriateness of colonoscopy: a multi-center, international, observational study

OBJECTIVE

To examine the appropriateness and necessity of colonoscopy across Europe.

DESIGN

Prospective observational study.

SETTING

A total of 21 gastrointestinal centers from 11 countries.

PARTICIPANTS

Consecutive patients referred for colonoscopy at each center.

INTERVENTION

Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy.

MAIN OUTCOME MEASURE

Appropriateness of colonoscopy.

RESULTS

A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45-54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia [OR: 30.84, 95% CI: 19.79-48.06] or change in bowel habits [OR: 3.69, 95% CI: 2.74-4.96] were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain [OR: 0.64, 95% CI: 0.49-0.83] or chronic diarrhea [OR: 0.54, 95% CI: 0.40-0.75] were less likely to have an appropriate or necessary indication.

CONCLUSIONS

This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptoms.

Variations in colonoscopy practice in Europe: a multicentre descriptive study (EPAGE)

OBJECTIVE

The volume of colonoscopies performed is increasing and differences in colonoscopy practice over time and between centres have been reported. Examination of current practice is important for bench-marking quality. The objective of this study was to examine variations in colonoscopy practice in endoscopy centres internationally.

MATERIAL AND METHODS

This observational study prospectively included consecutive patients referred for colonoscopy from 21 centres in 11 countries. Patient, procedure and centre characteristics were collected through questionnaires. Descriptive statistics were performed and the variation between centres while controlling for case-mix was examined.

RESULTS

A total of 6004 patients were included in the study. Most colonoscopies (93%; range between centres 70-100%) were performed for diagnostic purposes. The proportion of main indications for colonoscopy showed wide variations between centres, the two most common indications, surveillance and haematochezia, ranging between 7-24% and 5-38%, respectively. High-quality cleansing occurred in 74% (range 51-94%) of patients, and 30% (range 0-100%) of patients received deep sedation. Three-quarters (range 0-100%) of the patients were monitored during colonoscopy, and one-quarter (range 14-35%) underwent polypectomy. Colonoscopy was complete in 89% (range 69-98%) of patients and the median total duration was 20 min (range of centre medians 15-30 min). The variation between centres was not reduced when case-mix was controlled for.

CONCLUSIONS

This study documented wide variations in colonoscopy practice between centres. Controlling for case-mix did not remove these variations, indicating that centre and procedure characteristics play a role. Centres generally were within the existing guidelines, although there is still some work to be done to ensure that all centres attain the goal of providing high-quality colonoscopy.

Use, appropriateness, and diagnostic yield of screening colonoscopy: an international observational study (EPAGE)

BACKGROUND

Screening for colorectal cancer (CRC) has been shown to decrease mortality.

OBJECTIVE

To examine determinants associated with having (1) a screening colonoscopy, (2) an appropriate indication for screening, and (3) a significant diagnosis at screening.

DESIGN

Prospective observational study.

SETTING

Twenty-one endoscopy centers from 11 countries.

PATIENTS

Asymptomatic patients who underwent a colonoscopy for the purpose of detecting CRC and who did not have a history of polyps or CRC, a lesion observed at a recent barium enema or sigmoidoscopy, or a recent positive fecal occult blood test.

INTERVENTION

Screening colonoscopy.

MAIN OUTCOME MEASUREMENTS

Appropriateness according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria and significant diagnoses (cancer, adenomatous polyps, new diagnoses of inflammatory bowel disease, angiodysplasia).

RESULTS

Of 5069 colonoscopies, 561 (11%) were performed for screening purposes. Patients were more likely to have a screening colonoscopy if they were aged 45 to 54 years (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.60-3.99). Screening colonoscopies were appropriate, uncertain, and inappropriate in 26%, 60%, and 14% of cases, respectively. Eighty-one significant diagnoses were made, including 4 cancers. Significant diagnoses were more often made for uncertain/appropriate indications (OR 3.20, 95% CI 1.12-9.17) than for inappropriate indications.

LIMITATIONS

Although data completeness was asked of all centers, it is possible that not all consecutive patients were included. Participating centers were a convenience sample and thus may not be representative.

CONCLUSIONS

About 1 of 10 colonoscopies were performed for screening, preferentially in middle-aged individuals. A higher diagnostic yield in uncertain/appropriate indications suggests that the use of appropriateness criteria may enhance the efficient use of colonoscopy for screening.

Applicability and efficacy of qualifying criteria for an appropriate use of diagnostic upper gastrointestinal endoscopy

Appropriate indication for upper gastrointestinal endoscopy (UGE) may be facilitated by referring to qualifying criteria such as those devised by the European Panel (EPAGE) and French Experts (ANAES). This prospective study evaluates the applicability and efficacy of these criteria in clinical practice.

PATIENTS AND METHODS

A total of 522 patients was included (55% inpatients, 57% male, mean age 55 years). Appropriateness of referral was evaluated using EPAGE and ANAES criteria sets by a single independent expert.

RESULTS

EPAGE criteria were applicable in 71% of cases. Indications for UGE were appropriate, inappropriate and uncertain in 62%, 27% and 11% respectively; 74%, 16% and 10% of clinically significant lesions detected by UGE were disclosed in patients having appropriate, inappropriate and uncertain indications respectively. ANAES criteria were applicable in 81% of cases. Indications for UGE were appropriate in 74%, inappropriate in 26%; 76% and 24% of clinically significant lesions detected by UGE were disclosed in patients having appropriate and inappropriate indications respectively. Whatever the criteria set used, all cancers and most of the severe lesions were observed in patients with appropriate indications: those patients were more often in-patients and were significantly older than patients belonging to the inappropriate group.

CONCLUSION

Reference to EPAGE and ANAES qualifying criteria facilitates patient selection for UGE. Final decision must however rely upon practitioner advice. ANAES criteria are significantly more often applicable than EPAGE ones. However EPAGE referential when applicable is more predictive of the UGE findings.

Appropriateness of colorectal cancer screening: appraisal of evidence by experts

OBJECTIVE

. To evaluate how the level of evidence perceived by an international panel of experts was concordant with the level of evidence found in the literature, to compare experts perceived level of evidence to their appropriateness scores, and to compare appropriateness criteria for colonoscopy between experts and an evidence-based approach.

DESIGN

Comparison of expert panel opinions and systematic literature review regarding the level of evidence and appropriateness of colonoscopy indications.

PARTICIPANTS

European Panel on the Appropriateness of Gastrointestinal Endoscopy multidisciplinary experts from 14 European countries.

MAIN OUTCOME MEASURES

Concordance and weighted kappa coefficient between level of evidence as perceived by the experts' and that found in the literature, and between panel- and literature-based appropriateness categories.

RESULTS

Experts overestimated the level of published evidence of 57 indications. Concordance between the level of evidence perceived by the experts and the actual level of evidence found in the literature was 36% (weighted kappa 0.18). Indications for colonoscopy were reported to be appropriate, uncertain, and inappropriate by the experts in 54, 19, and 27% of the cases, and by the literature in 37, 46, and 17% of the cases. A 46% agreement (weighted kappa 0.29) was found between literature-based and experts' appropriateness criteria.

CONCLUSIONS

Experts often overestimated the level of evidence on which they based their decisions. However, rarely did the experts' judgement completely disagree with the literature, although concordance between panel- and literature-based appropriateness was only fair. A more explicit discussion of existing evidence should be undertaken with the experts before they evaluate appropriateness criteria.

Évaluer la spécificité d’un centre hospitalo-universitaire

OBJECTIVE

The specificity of a University Hospital Centre is usually assessed from its teaching and research capacity. The EPAGE survey, an instrument used to help decision making available on the Internet, permitted us to compare the prescription of a routine exploration, gastrointestinal endoscopy, between the University Hospital Center in Clermont-Ferrand and the Hospital Centre in Moulins. The aim was to demonstrate the differences in daily practice between these two geographically close hospital centres and hence to underline the specificity of a University Hospital Centre that is not taken into account in the financing systems of such hospitals. Method The data collected were taken from the EPAGE trial, a prospective mutlicentre study that included 21 European and Canadian centres. Data was collected from the University Hospital centre in Clermont-Ferrand over two periods: from December 2000 to March 2001, then from December 2001 to February 2002, and from the Hospital Centre in Moulins, from December 2000 to the end of November 2001. For this Article, only the patients' characteristics, indications for gastrointestinal endoscopy and opportunity rate were analysed. Comparison of patients' categories from the 2 centres was conducted according to their DRG (diagnostic related group) (homogeneous patient group) classification, thus allowing calculation of the mean of the SIA (synthetic index of activity) points in the two centres.

RESULTS

221 cases of gastrointestinal endoscopy performed in the University Hospital centre and 292 in the Hospital Centre were included in the survey. No statistically significant difference was found in the reasons motivating a gastrointestinal endoscopy, with regard to the indications listed on the EPAGE website. There were 18% of unlisted indications in the University Hospital Centre versus 4.8% in the Hospital Centre (p<1.10-6). Using the DRG nomenclature, calculation of the mean SIA points at the University Hospital Centre per patient was of 1161 versus 1147: non significant deviation of 1.2% in favour of the University Hospital Centre.

DISCUSSION

- Conclusion The difference in reasons motivating a gastrointestinal endoscopy found between the two centres concerned rare, complex or innovating situations. This illustrates the role of a Regional Reference University Hospital Centre, an aspect clearly underestimated when measuring mixed cases according to the HPG. Study of the financing and/or information systems is warranted and might resolve the apparent underestimation of the current financing system.

Appropriateness of diagnostic digestive endoscopy

The indications of diagnostic endoscopy--upper gastrointestinal endoscopy or colonoscopy--in the exploration of the digestive tract are classified as appropriate or inappropriate with regard to criteria established in guidelines supported by national scientific societies and by insurance companies. This applies to the exploration of symptomatic patients and to screening protocols for malignant lesions. Functional or nonstructural diseases being more frequent than structural diseases, negative findings in endoscopy are common. However this reassures the patient and should not be considered as overuse. On the other hand excess in the repetition of negative endoscopic procedures during surveillance raises ethical problems, increased costs, and may be considered as unethical.

Effect of specialty and nationality on panel judgments of the appropriateness of coronary revascularization: a pilot study

BACKGROUND

Appropriateness criteria are frequently used to assess quality of care. However, assessing care in one country with criteria developed in another may be misleading. One approach to measuring care across countries would be to develop common standards using physicians from different countries and specialties.

OBJECTIVE

To identify the degree to which appropriateness ratings for coronary revascularization developed by a multinational panel differ by panelist specialty and nationality.

METHODS

A 13-member panel of cardiothoracic surgeons and cardiologists from the Netherlands, Spain, Sweden, Switzerland, and the United Kingdom was convened to rate the appropriateness of 842 indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG) on a 1 (extremely inappropriate) to 9 (extremely appropriate) scale.

MEASURES

Mean appropriateness ratings by panelist specialty and nationality.

RESULTS

Surgeons' mean ratings for PTCA indications ranged from 0.64 points lower than the corresponding ratings of the cardiologists for acute myocardial infarction indications to 1.22 points lower for chronic stable angina indications. Conversely, their ratings for bypass surgery indications ranged from 0.59 points higher for chronic stable angina indications to 0.69 points higher for unstable angina indications. Although Spanish panelists' ratings were significantly higher than the mean for 3 of the 4 clinical conditions treated by PTCA, their ratings were similar for bypass surgery indications. No specific patterns were observed in the ratings of the panelists from the other countries.

CONCLUSIONS

These findings support the use of physicians from multiple specialties on appropriateness panels because they represent more divergent views than physicians from a single specialty. Finding no systematic difference in beliefs regarding the appropriateness of PTCA and CABG among physicians from different countries will require confirmation before multinational panels supplant single country panels in future studies.

The appropriateness of use of percutaneous transluminal coronary angioplasty in Spain

BACKGROUND

The rapid increase in the number of percutaneous transluminal coronary angioplasty (PTCA) procedures performed in Spain in recent years raises questions about how appropriately this procedure is being used. To examine this issue, we studied the appropriateness of use of PTCA in Spanish patients and factors associated with inappropriate use.

METHODS

We applied criteria for the appropriate use of PTCA developed by an expert panel of Spanish cardiologists and cardiovascular surgeons to a random sample of 1913 patients undergoing PTCA in Spain in 1997. The patients were selected through a two-step sampling process, stratifying by hospital type (public/private) and volume of procedures (low/medium/high). We examined the association between inappropriate use of PTCA and different clinical and sociodemographic factors.

RESULTS

Overall, 46% of the PTCA procedures were appropriate, 31% were uncertain and 22% were inappropriate. Two factors contributing to inappropriate use were patients' receipt of less than optimal medical therapy and their failure to undergo stress testing. Institutional type and volume of procedures were not significantly related with inappropriate use.

CONCLUSIONS

One of every five PTCA procedures in Spain is done for inappropriate reasons. Assuring that patients receive optimal medical therapy and undergo stress testing when indicated could contribute to more appropriate use of PTCA.

Overuse and underuse of colonoscopy in a European primary care setting

BACKGROUND

Efforts to decrease overuse of health care may result in underuse. Overuse and underuse of colonoscopy have never been simultaneously evaluated in the same patient population.

METHODS

In this prospective observational study, the appropriateness and necessity of referral for colonoscopy were evaluated by using explicit criteria developed by a standardized expert panel method. Inappropriate referrals constituted overuse. Patients with necessary colonoscopy indications who were not referred constituted underuse. Consecutive ambulatory patients with lower gastrointestinal (GI) symptoms from 22 general practices in Switzerland, a country with ready access to colonoscopy, were enrolled during a 4-week period. Follow-up data were obtained at 3 months for patients who did not undergo a necessary colonoscopy.

RESULTS

Eight thousand seven hundred sixty patient visits were screened for inclusion; 651 patients (7.4%) had lower GI symptoms (mean age 56.4 years, 68% women). Of these, 78 (12%) were referred for colonoscopy. Indications for colonoscopy in 11 patients (14% of colonoscopy referrals or 1.7% of all patients with lower GI symptoms) were judged inappropriate. Among 573 patients not referred for the procedure, underuse ranged between 11% and 28% of all patients with lower GI symptoms, depending on the criteria used.

CONCLUSIONS

Applying criteria from an expert panel of nationally recognized experts indicates that underuse of referral for colonoscopy exceeds overuse in primary care in Switzerland. To improve quality of care, both overuse and underuse of important procedures must be addressed.

European criteria for the appropriateness and necessity of coronary revascularization procedures

OBJECTIVES

Large variations in the use of coronary revascularization procedures have led many countries to apply the RAND appropriateness method to develop specific criteria describing patients who should be offered these procedures. The method is based on the work of a multidisciplinary expert panel that reviews a synthesis of the scientific evidence and rates the appropriateness of a comprehensive list of indications for the procedure being studied. Previous studies, however, have all involved single-country panels. We tested the feasibility of carrying out a multinational panel to rate the appropriateness and necessity of coronary revascularization, thereby producing recommendations for common European criteria.

METHODS

Using the RAND methodology, a multispecialty (interventional cardiologists, non-interventional cardiologists and cardiovascular surgeons), multinational (The Netherlands, Spain, Sweden, Switzerland and the United Kingdom) panel rated the appropriateness and necessity of indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). A synthesis of the evidence and list of indications for PTCA and CABG were sent to 15 panelists, three from each country, who performed their ratings in three rounds.

RESULTS

For PTCA, 24% of the indications were appropriate and necessary, 16% were appropriate, 43% were uncertain and 17% were inappropriate. The corresponding values for CABG were 33% appropriate and necessary, 7% appropriate, 40% uncertain and 20% inappropriate. The proportion of indications rated with disagreement was 4% for PTCA and 7% for CABG.

CONCLUSION

Multinational panels appear to be a feasible method of addressing issues concerning the appropriateness and necessity of medical procedures in western European countries. The criteria produced provide a common tool that can be used to measure the overuse and underuse of medical procedures and to guide decision-making.