Abstract
Background: Potentially inappropriate care can result from overuse or underuse of treatments, tests, or procedures. Overuse is defined as the use of health services with no clear benefit to the recipient or where harms outweigh benefits and/or costs of care. Underuse is defined as failure to deliver an effective and cost-effective healthcare intervention. Cardiovascular procedures such as coronary artery bypass grafting, carotid endarterectomy, coronary angiography, and coronary angioplasty (with/without stenting) are potentially both underused and overused. This systematic review aims to identify rates of potential overuse and underuse of these cardiovascular procedures and explore any associated patient or healthcare system factors. Methods: A systematic review and meta-analysis will be conducted in accordance with the PRISMA guidelines. A systematic search of MEDLINE (via Ovid), Embase, Cumulative Index to Nursing and Allied Health Literature and the Cochrane library will be conducted using a predefined search strategy. Eligible studies for inclusion will examine rates of overuse and underuse of cardiovascular procedures, measured against national/international guidelines, for adults aged ≥18 years. Primary observational studies including cross-sectional and cohort studies will be included. Titles, abstracts, and full texts will be screened forinclusionby two reviewers. Data will be extracted using a standardised form. Risk of bias for all included studies will be assessed using a modified version of the Hoy risk of bias tool. Where adequate data exists, and if statistically appropriate, meta-analyses will be conducted. If statistical pooling of the data is not possible, the findings will be narratively summarised focusing on the review's objectives. Conclusion: This systematic review will examine overuse and underuse of cardiovascular procedures for adults. The results will help inform policy makers, researchers, patients, and clinicians in the appropriate use of these procedures, in line with international guidelines. Registration: This protocol has been submitted for registration on PROSPERO (CRD42021239041).
Highlights
Variation in healthcare can occur for various complex and interrelated reasons[1]
Inappropriate care can result from overuse or underuse of treatments, tests, or procedures[5]
An American study conducted using the RAND-UCLA appropriateness method[23] across four public hospitals and two private hospitals in Los Angeles found that 26% of patients who underwent coronary angiography (CA) (n=107), and where percutaneous transluminal coronary angioplasty (PTCA) was deemed necessary, did not receive the procedure[20]
Summary
Variation in healthcare can occur for various complex and interrelated reasons[1]. Examples of variation include geographical, gender or age differences, patient or clinician preference in relation to conditions where more than one treatment option exists (preference-sensitive care), or availability and access to particular treatments or services (supply-sensitive care)[1,2]. Identify rates of potential overuse and potential underuse of the following cardiovascular procedures; CABG, CEA, CA, and coronary angioplasty (with/ without stenting), for community-dwelling adults (aged ≥18 years) benchmarked against national or international guidelines. Rates of potential inappropriateness (overuse or underuse) of cardiovascular therapeutic procedures namely, coronary angiography, coronary angioplasty (with/without stenting), coronary artery bypass grafting and carotid endarterectomy, measured against national or international guidelines. Data collection and extraction Two reviewers (DQ and DB) will use a standardised, prepiloted form (see extended data27) to extract data on the following: study ID, authors, year of publication, dates of study, inclusion and exclusion criteria, country of study, disease and/or symptom being studied, cardiovascular procedure, number of patients and other patient demographics, name and type (national/ international) of guidelines measuring appropriateness, guideline reference, name of guideline-issuing authority (and country), year of guideline publication, guideline recommendations, method of primary study data collection, number of patients that potentially inappropriately received the cardiovascular procedure (overuse), and/or number of patients that potentially inappropriately did not receive the cardiovascular procedure (underuse). It is anticipated that data collection and analysis should be complete by October 2021
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