This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (3)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Topic Collections  • Cardiovascular System  • Randomized Controlled Trial  • Diagnosis  • Cardiovascular Disease/ Myocardial Infarction  • Alert me on articles by topic  Social Bookmarking   What's this?

Appropriateness of Referral and Investigation in Angina (ARIA) Trial

Cornelia Junghans, PhD; Gene Feder, MD; Adam D. Timmis, FRCP; Sandra Eldridge, PhD; Neha Sekhri, MRCP; Nick Black, MD; Paul Shekelle, MD; Harry Hemingway, FRCP

Arch Intern Med. 2007;167(2):195-202.

Background  Conventional guidelines have limited effect on changing physicians' test ordering. We sought to determine the effect of patient-specific ratings vs conventional guidelines on appropriate investigation of angina.

Methods  Randomized controlled trial of 145 physicians receiving patient-specific ratings (online prompt stating whether the specific vignette was considered appropriate or inappropriate for investigation, with access to detailed information on how the ratings were derived) and 147 physicians receiving conventional guidelines from the American Heart Association and the European Society of Cardiology. Physicians made recommendations on 12 Web-based patient vignettes before and on 12 vignettes after these interventions. The outcome was the proportion of appropriate investigative decisions as defined by 2 independent expert panels.

Results  Decisions for exercise electrocardiography were more appropriate with patient-specific ratings (819/1491 [55%]) compared with conventional guidelines (648/1488 [44%]) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.36-1.82). The effect was stronger for angiography (1274/1595 [80%] with patient-specific ratings compared with 1009/1576 [64%] with conventional guidelines [OR, 2.24; 95% CI, 1.90-2.62]). Within-arm comparisons confirmed that conventional guidelines had no effect but that patient-specific ratings significantly changed physicians' decisions toward appropriate recommendations for exercise electrocardiography (55% vs 42%; OR, 2.62; 95% CI, 2.14-3.22) and for angiography (80% vs 65%; OR, 2.10; 95% CI, 1.79-2.47). These effects were robust to physician specialty (cardiologists and general practitioners) and to vignette characteristics, including older age, female sex, and nonwhite race/ethnicity.

Conclusion  Patient-specific ratings, unlike conventional guidelines, changed physician testing behavior and have the potential to reduce practice variations and to increase the appropriate use of investigation.

Author Affiliations: Department of Epidemiology and Public Health, University College London Medical School (Drs Junghans and Hemingway), Department of Primary Care, Queen Mary's School of Medicine and Dentistry, University of London (Drs Feder, Eldridge, and Sekhri), Cardiac Directorate, Barts and The London NHS Trust (Dr Timmis), and Department of Public Health and Policy, London School of Hygiene and Tropical Medicine (Dr Black), London, England; and Greater Los Angeles Veterans Affairs Health Care System, Los Angeles, Calif (Dr Shekelle).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Appropriateness Criteria for Coronary Angiography in Angina: Reliability and Validity
Hemingway et al.
ANN INTERN MED 2008;149:221-231.
ABSTRACT | FULL TEXT  

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris
Sekhri et al.
BMJ 2008;336:1058-1061.
ABSTRACT | FULL TEXT