The appropriateness of use of coronary angiography in Lebanon: implications for health policy

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Lebanon, characterized by a free-market health care system, has one of the highest reported per capita rates of cardiac catheterization facilities and coronary angiographies in the world. The aim of this study is to evaluate the appropriateness of performance of coronary angiography procedures in Lebanon. Data derived from the 2004 Lebanese Interventional Coronary Registry (LICOR) included 5418 patients aged 30 years and older who had not undergone prior percutaneous coronary intervention or coronary artery bypass grafting. Appropriateness was evaluated based on the Class I indications of the ACC/AHA guidelines for coronary angiography. The overall rate of appropriate procedures was 54.7% (95% CI 53.3-56.0%). Appropriateness varied significantly by gender and across administrative regions. Compared with females, males were more likely to be referred appropriately for coronary angiography (OR = 1.28, 95% CI = 1.15-1.44). Appropriateness was lowest (OR = 0.89, 95% CI = 0.71-1.12) in the region where the per capita density of cardiac catheterization labs increased by six-fold in the latter 2 years. The majority of the patients (84.3%) were not evaluated by any of the non-invasive tests prior to angiography, with only 10.8%, 4% and 1.5% of the patients referred for an exercise stress test, stress echocardiography and thallium stress tests, respectively. Findings indicate a high rate of procedures conducted without appropriate indications and a low utilization rate of pre-interventional non-invasive testing. This may be attributed to three factors: a surplus of catheterization facilities in certain regions, the insignificant cost gradient between non-invasive testing and coronary angiography, and the wide case-based reimbursement of coronary angiography, unlike non-invasive testing, by public insurance schemes.