Development of appropriateness criteria for percutaneous coronary intervention and coronary artery bypass graft surgery using a consensus panel of experts

Recent advances in medical devices for ischemic heart disease are expected to expand the indication of percutaneous coronary intervention (PCI). In Japan, however, the number of PCI procedures is already about six times as large as that of coronary artery bypass graft surgery (CABG), which is much larger than western countries where these numbers are about the same, possibly suggesting different criteria of indication in practice. To elucidate the indication criteria used in Japan, we developed a set of appropriateness criteria using the UCLA/RAND Appropriateness Methods. A panel of 9 nationally recognized experts was recruited from all over Japan (7 interventional cardiologists and 2 cardiac surgeons). Based on clinical evidence and professional opinion, they rated the appropriateness of performing PCI and CABG in over 2000 clinical scenarios twice. Between the first and second rating, a face-to-face discussion meeting was held. In contrast to traditional guideline recommendations, some left main diseases were considered to be appropriate for PCI while some single-and two-vessel diseases were inappropriate for CABG. About half of the clinical scenarios had an "indeterminate" agreement level. These findings may explain the higher PCI/CABG ratio in Japan. The area in which no agreement was revealed should be explored in clinical research.