Underuse of coronary revascularization procedures: application of a clinical method.

OBJECTIVES: Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients. BACKGROUND: Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before. METHODS: The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated. RESULTS: Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005). CONCLUSIONS: Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.

Effect of physician specialty on use of necessary coronary angiography.

OBJECTIVES: This study sought to determine whether having a cardiologist as a regular source of care influences likelihood of undergoing necessary coronary angiography. BACKGROUND: An important element of the current health policy debate is the respective roles of primary care and specialist physicians. However, there are few data on interspecialty differences in quality of care for patients with ischemic heart disease. METHODS: We contacted 243 patients by telephone (response rate 72%) who had positive (or very positive) exercise stress test results and met additional clinical criteria for necessary coronary angiography. Study patients were randomly sampled from those undergoing exercise stress testing at one university and three public hospitals in Los Angeles between January 1, 1990 and June 30, 1991. Patients were asked whether they had a regular source of care during the time after their exercise stress test and, if so, whether that provider was a cardiologist or cardiology clinic. RESULTS: Among survey responders, 47% underwent necessary coronary angiography within 3 months of exercise testing and 61% within 12 months. After adjustment for sociodemographics and clinical presentation, patients with a cardiologist as a regular source of care were more likely than all other patients to have undergone necessary angiography within 3 months (52% vs. 38%, p = 0.05) and within 12 months (74% vs. 44%, p = 0.0001) of the exercise test. At 3 months, there was a trend toward a more pronounced effect of ongoing cardiologic care within the public hospitals compared with the private hospital (p = 0.09 for interaction between hospital types). CONCLUSIONS: Patients with a cardiologist as a regular source of care were more likely than all other patients to undergo clinically necessary coronary angiography within both 3 and 12 months of exercise stress testing.

Measuring the quality of outpatient treatment for schizophrenia.

BACKGROUND: Consumers and policy makers are increasingly interested in measuring treatment quality. We developed a standardized approach to measuring the quality of outpatient care for schizophrenia and used it to evaluate routine care. METHODS: We randomly sampled 224 patients in treatment for schizophrenia at 2 public mental health clinics. Appropriate medication management was defined according to criteria derived from national treatment recommendations, and focused on recent management of symptoms and side effects. Adequate psychosocial care was defined as the recent provision of case management or family management to patients for whom it is indicated. Care was evaluated using patient interviews and medical records abstractions. RESULTS: Although patients at the 2 clinics had similar illnesses, the treatment they received was quite different. In total, 84 (38%) of patients received poor-quality medication management, and 117 (52%) had inadequate psychosocial care. Clinics differed in the proportion of patients receiving poor-quality medication management not attributable to patient factors (28% vs 16%). The clinic with better-quality medication management provided case management to fewer severely ill patients (48% vs 81%). More than half of the cases of poor care would not have been detected if we had used only medical records data. CONCLUSIONS: At these clinics, many schizophrenic patients were receiving poor-quality care and most poor care was likely due to factors that can be modified. One approach to improving care begins by developing systems that monitor quality. These systems may require improved medical records and patient-reported symptoms and side effects.

Persuasive communication and medical technology assessment.

Assessments of medical technologies with respect to their efficacy, safety, and cost-effectiveness are expected to influence clinical practice, but they are often lost in an avalanche of medical information. We developed a conceptual model that may aid understanding of the potential impact on clinical practice of new medical information in general and assessment information in particular. The model identifies aspects of medical communication that may influence an assessment's subsequent impact, including sources, messages, channels, audiences, and settings. We reviewed the literature on how medical information diffuses to physicians and highlighted those factors likely to heighten physicians' awareness and decisions to incorporate recommended medical advances. We outlined implications for educational interventions and promising research directions.

Assessing use of primary health care services by very low-income adults in a managed care program.

OBJECTIVE: To assess the effect of providing free health care services to low-income adults. METHODS: We measured access to primary care services by enrollees with 4 chronic medical conditions in the General Relief Health Care Program (GRHCP), a program designed for adults receiving General Relief (GR). Implemented by the Los Angeles County Health Department in October 1995, the GRHCP is composed of private and public health care facilities. As adults registered for GR, they were asked to complete a baseline health survey, were enrolled in the GRHCP, and assigned a health care provider. A total of 8520 surveys were completed between September and November 1996 (98% response rate). The analyses of this article are limited to individuals (N = 2164) who reported a history of hypertension, diabetes mellitus, a nonresolving cough, or substance dependence. We reviewed medical records to determine whether new GR recipients had visited their designated GRHCP provider within 4 months of enrollment and used multivariate logistic regression to assess the effect of individual patient factors on the use of free health care. RESULTS: A total of 17% of individuals visited their assigned GRHCP provider within 4 months of enrollment. In multivariate analysis, patients were more likely to have made a visit if they were younger than 50 years, were female, were Asian/Pacific Islander, reported needing to see a physician, or had seen a physician within 12 months. CONCLUSIONS: It is not sufficient to merely supply the name and address of a health care provider to this population. More aggressive efforts should be attempted to increase utilization of services for patients with medical conditions responsive to ambulatory care.

The appropriateness of use of cardiovascular procedures in women and men.

OBJECTIVE: To determine whether there are differences between women and men in the appropriateness of use of cardiovascular procedures. DESIGN: Retrospective chart review. SETTING: Thirty hospitals located in New York State. PATIENTS: Random sample of 3979 patients undergoing coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery in 1990. MEASURES: We evaluated two measures: (1) the percent of women and men who underwent cardiovascular procedures for appropriate, uncertain, and inappropriate indications and (2) for coronary angiography patients, the prognostic exercise stress treadmill score that predicts before the coronary angiogram the 5-year probability of death from a cardiovascular event. RESULTS: The inappropriate rate of use of cardiovascular procedures was low and not significantly different for men and women (4% vs 5% for coronary angiography; 4% vs 3% for percutaneous transluminal coronary angioplasty; and 2% vs 3% for coronary artery bypass graft surgery, respectively), and the use of these procedures for uncertain reasons also did not vary significantly by gender. There was also no significant gender difference in the predicted risk of death from a cardiovascular event for coronary angiography patients: 24% of men and 22% of women were at high risk (ie, < 75% 5-year survival rate) and 20% and 16%, respectively, were at low risk (ie, > or = 95% 5-year survival rate). CONCLUSION: Based on two indicators, the RAND appropriateness score and the Duke prognostic exercise treadmill score, we were unable to find any evidence of a difference in the clinical appropriateness of use of these three cardiovascular procedures between women and men.

Outcomes of patients with do-not-resuscitate orders. Toward an understanding of what do-not-resuscitate orders mean and how they affect patients.

OBJECTIVES: To evaluate the outcomes of hospitalized patients with do-not-resuscitate (DNR) orders and to identify variables that may elucidate the high mortality of patients with DNR orders. METHODS: Among a nationally representative sample of Medicare patients hospitalized with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture, we retrospectively studied in-hospital and 180-day mortality and hospital lengths of stay for patients without DNR orders, with early (day 1 or 2) DNR orders, and with late (day 3 or later) DNR orders, before and after adjustment for sickness at hospital admission and patient and hospital characteristics. RESULTS: In-hospital mortality for patients with DNR orders exceeded that for patients without DNR orders before adjustment (59% vs 8%, P < .001), and after accounting for differences in sickness at admission and patient and hospital characteristics (40% vs 9%, P < .001). Sicker patients were assigned earlier DNR orders. Yet, patients with early DNR orders had a lower adjusted in-hospital mortality (31% vs 49%, P < .001) and shorter hospital stay (10 vs 18 days, P < .001) than did patients with late DNR orders. CONCLUSIONS: Hospitalized older patients with DNR orders have a much higher mortality than predicted by admission demographic and clinical characteristics. The differential association of early and late DNR orders with mortality indicates that DNR orders represent a heterogeneous group of interventions that may be a marker of unmeasured sickness and a determinant of quality of care. A better understanding of what the DNR order represents and its effect on patient care is needed to ensure optimal use.

Member ratings of health care provided by 48 physician groups.

BACKGROUND: Satisfaction with health plan performance has been assessed frequently, but assessment of physician group performance is rare. OBJECTIVE: To present ratings of the care provided by physician groups to enrollees in a variety of capitated health maintenance organization plans. METHODS: A random sample was drawn of adult enrollees receiving managed health care from 48 physician groups in a group practice association. Each individual in the sample was mailed a 12-page questionnaire and 7093 were returned (59% response rate). The mean age of those returning the questionnaire was 51 years; 65% were women. RESULTS: Reliability estimates for 6 multi-item satisfaction scales were excellent, and noteworthy differences in ratings among groups were observed. In particular, ratings of overall quality ranged from a low of 28 to a high of 68 (mean, 50; SD, 10). Average scores for physician groups were strongly correlated across all scales, but no single group scored consistently highest or lowest on the different scales. Negative ratings of care were significantly related to the following: intention to switch to another physician group, difficulty in getting appointments, lengthy waiting periods in the reception area and examination room, the inability to get consistent care from one physician for routine visits, and not being informed by the office staff when there was a delay in seeing the primary care provider. CONCLUSIONS: Monitoring of health care quality at the physician group level is possible, and could be used for benchmarking, internal quality improvement, and for providing information to the public about how these physician groups will meet its needs.

Quality of care for hospitalized depressed elderly patients before and after implementation of the Medicare Prospective Payment System.

OBJECTIVE: The authors evaluated the impact of Medicare's Prospective Payment System on aspects of quality of care and outcomes for depressed elderly inpatients in acute-care general medical hospitals. METHOD: The depressed elderly inpatients (N = 2,746) were hospitalized in 297 acute-care general medical hospitals. The authors used a retrospective before-and-after design, controlling for differences over time in sickness at admission. Quality of care and outcomes were assessed through clinical review of explicit and implicit information in the medical records; secondary data sources provided information on postdischarge outcomes. RESULTS: After implementation of the prospective payment system 1) a higher percentage of patients had clinically appropriate acute-care admissions; 2) the initial assessment of psychological status by the treating provider was more complete; 3) the quality of psychotropic medication management, as rated by the study psychiatrists, improved; 4) the rates of any inpatient medical or psychiatric complication, of discharge to another hospital or a nursing home, and of inpatient readmission declined; and 5) there was no marked change in the percentage of patients rated by study clinicians as having acceptable overall clinical status at discharge or the rate of mortality 1 year after admission. CONCLUSIONS: After the implementation of the Medicare Prospective Payment System, the quality of care for depressed elderly inpatients improved and there was no marked increase in adverse clinical outcomes. Despite these gains, after implementation the quality of care was moderate at best and over one-third of the patients had unacceptable clinical status at discharge.

Relation between hospital experience and in-hospital mortality for patients with AIDS-related Pneumocystis carinii pneumonia: experience from 3,126 cases in New York City in 1987.

There is marked debate about whether outcomes of care, particularly mortality, vary as a function of hospital and physician experience with a disease. This issue is especially important with respect to AIDS because greater than 200,000 individuals have now been diagnosed with this disease. We analyzed discharge data for 3,126 persons with AIDS who had Pneumocystis carinii pneumonia and who were treated at one of 73 New York City hospitals in 1987. In-hospital mortality was 25%. Factors associated with higher chances of short-term death were older age, being black, not having private health insurance, and being severely ill. A logistic regression model indicated that after controlling for differences in patient and hospital characteristics, the chances of death decreased when care was given at hospitals with higher caseloads of patients with Pneumocystis carinii pneumonia. Our findings suggest that hospital experience may decrease mortality in this subset of patients with human immunodeficiency virus disease, although it is unknown whether this is due to differences in quality of care.

Underuse and overuse of diagnostic testing for coronary artery disease in patients presenting with new-onset chest pain.

PURPOSE: To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests. SUBJECTS AND METHODS: We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire. RESULTS: Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4). CONCLUSION: Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

Childhood enuresis: prevalence, perceived impact, and prescribed treatments.

Childhood enuresis can indicate an underlying problem as benign as developmental immaturity or as serious as urinary tract obstruction. As part of a large population-based study, parents of 1,753 children aged 5 to 13 years were asked about the presence and frequency of enuresis, perceived impact, and physician-prescribed treatments. Enuresis at least once during a 3-month period was reported for 14% of this general population of children. Boys were significantly more likely to experience enuresis than girls (16% v 12%; P less than .01). The prevalence of enuresis at least once a week was similar among boys and girls (7% v 6%). Parents reported that more than half of the children are distressed by their enuresis, and two thirds of parents expressed concern. Thirty-eight percent of bed wetters have seen a physician about their condition. More than one third of these children have been treated with a drug. The most commonly recommended regimen in the literature, the bed alarm, was prescribed to only 3% of bed-wetting children who saw a physician.

The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior.

CONTEXT: Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided. OBJECTIVES: To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction. DESIGN: Previsit and postvisit survey of parents and postvisit survey of physicians. SETTING: Two private pediatric practices, one community based and one university based. PARTICIPANTS: Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians. MAIN OUTCOME MEASURES: Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction. RESULTS: Based on multivariate analysis, physicians' perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction. CONCLUSIONS: The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Prepaid group practice effects on the utilization of medical services and health outcomes for children: results from a controlled trial.

A total of 693 children between the ages of 0 and 13 years were randomly assigned to either a staff model HMO or to one of several fee-for-service insurance plans in Seattle to evaluate differences in medical expenditures and health outcomes. Although the fee-for-service plans varied the amount of cost sharing (0% to 95%), all children were covered for the same medical services, for either 3 or 5 years. No differences in imputed total expenditures were observed for children assigned to the HMO or any of the fee-for-service plans. Children with cost-sharing fee-for-service plans, however, had fewer medical contacts and received fewer preventive services than those assigned to the HMO. Nonetheless, children with the cost-sharing fee-for-service plans were perceived (by their mothers) to be in better health overall than those assigned to the HMO. No significant differences regarding physiological outcomes (eg, visual acuity, hemoglobin level) were observed between the two groups. The results of this experiment neither strongly support nor indict fee-for-service or prepaid care for children.

Consequences of cost-sharing for children's health.

Do children whose families bear a percentage of their health care costs reduce their use of ambulatory care compared with those families who receive free care? If so, does the reduction affect their health? To answer these questions, 1,844 children aged 0 to 13 years were randomly assigned (for a period of 3 or 5 years) to one of 14 insurance plans. The plans differed in the percentage of their medical bills that families paid. One plan provided free care. The others required up to 95% coinsurance subject to a +1,000 maximum. Children whose families paid a percentage of costs reduced use by up to one third. For the typical child in the study, this reduction caused no significant difference in either parental perceptions of their child's health or in physiologic measures of health. Confidence intervals are sufficiently narrow for most measures to rule out the possibility that large true differences went undetected. Nor were statistically significant differences observed for children at risk of disease. Wider confidence intervals for these comparisons, however, mean that clinically meaningful differences, if present, could have been undetected in certain subgroups.

The effect of comorbidity on appropriateness ratings for two gastrointestinal procedures.

We evaluated the effect of patients' comorbidity on the appropriateness of performing esophagogastroduodenoscopy or cholecystectomy. A nine-member national physician panel rated 1118 brief clinical scenarios for patients without comorbidity. Ratings were then repeated for patients with increasing degrees of comorbidity. As comorbidity changed from none to medium, 60% of those scenarios that were originally rated as appropriate for endoscopy and cholecystectomy remained appropriate. As high comorbidity was introduced, only 13% of such scenarios remained appropriate for endoscopy, while 33% remained appropriate for cholecystectomy. These findings suggest that, although clinical reasons for performing procedures are a powerful determinant of when they should be used, comorbidity is also important and needs to be included in any assessment of the appropriateness of procedure use.

The smoking gun: do clinicians follow guidelines on firearm safety counseling?

OBJECTIVES: To describe clinicians' behavior regarding firearm safety counseling practices, develop a model to predict current counseling behavior, and identify resources that might positively influence willingness to counsel according to medical guidelines. DESIGN: Four hundred sixty-five primary care Los Angeles County, California, pediatricians, family physicians, and pediatric nurse practitioners who serve families with children aged 5 years and younger received mailed questionnaires; 325 (70%) responded. MAIN OUTCOME MEASURE: Clinician self-reported behavior. RESULTS: Of the respondents, 80% stated that they should counsel on firearm safety; only 38% do so. Of those clinicians who currently counsel, only 20% counsel more than 10% of their patient families. Firearm safety counseling behavior is positively associated with a clinician being 49 years or younger (odds ratio [OR]=2.19, P=.02); a perception that counseling is beneficial (OR=2.62, P=.02); and household handgun ownership (OR=2.47, P=.02). Clinician households that report gun ownership counsel differently than those clinicians who report not possessing a household gun. There are no significant differences in the rates of counseling across specialties and crime area types. Forty-one percent of clinicians report that patient education handouts would increase their likelihood of counseling. CONCLUSIONS: In Los Angeles County gaps exist between clinicians' views of the benefits of counseling families with young children regarding firearm safety and their actual behavior. Guidelines and handouts are available from major medical organizations. Research should focus on how to get practitioners to use available materials, enabling them to better adhere to guidelines.

Keeping quality on the policy agenda.

Quality of care in the United States and elsewhere consistently fails to meet established standards. These failures subject patients to premature death and needless suffering. Yet, unlike the experience with other threats to life (tire failures or airplane rudders), public and private policymakers have been unable to maintain sufficient interest in identifying and solving problems with quality to change the way in which care is delivered. We discuss why it is hard to keep quality on the policy agenda and suggest short-term steps that are necessary if quality is to improve here and in the rest of the world.

Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group.

OBJECTIVE: To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN: Prospective survey and review of medical records. PATIENTS: Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES: Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS: Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS: Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.

The appropriateness of intention to treat decisions for invasive therapy in coronary artery disease in The Netherlands.

OBJECTIVE: To determine the appropriateness of intention to treat decisions concerning coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for patients with coronary artery disease in The Netherlands. DESIGN: Prospective study of intention to treat decisions using a computerised expert system. SETTING: "Presentation" sessions in 10 tertiary referral heart centres in 1992. PATIENTS: 3207 consecutive patients: 1618 CABG and 1589 PTCA candidates. MAIN OUTCOME MEASURE: Percentage of invasive treatment decisions rated appropriate, uncertain, or inappropriate by the expert system. RESULTS: PTCA decisions were common for patients with one-vessel disease and CABG decisions for patients with three-vessel and left main disease. PTCA decisions outnumbered CABG decisions in acute myocardial infarction. Of CABG decisions, 84% were rated appropriate, 12% uncertain, and 4% inappropriate. The proportions for PTCA decisions were 39% appropriate, 31% uncertain, and 29% inappropriate. Type C lesion was the main determinant of inappropriateness of PTCA decisions. If type C lesions were downgraded to type A/B lesions the rate of inappropriate PTCA decisions dropped to 6%. CONCLUSIONS: Clinicians in tertiary referral centres in The Netherlands favoured CABG if vessel disease was extensive or involved the left main artery, and PTCA for patients with less extensive disease and with acute myocardial infarction. Few CABG decisions were inappropriate. The main determinant of inappropriateness of PTCA decisions was its intended use in patients with type C lesions.