Measuring the clinical consistency of panelists' appropriateness ratings: The case of coronary artery bypass surgery

Richard L Kravitz, Rolla Edward Park, James P. Kahan

Research output: Contribution to journalArticlepeer-review

29 Scopus citations


Objective: To assess the clinical consistency of expert panelists' ratings of appropriateness for coronary artery bypass surgery. Design: Quantitative analysis of panelists' ratings. Participants: Nine physicians (three cardiothoracic surgeons, four cardiologists, and two internists) convened by RAND to establish criteria for the appropriateness of coronary artery bypass surgery. Main outcomes measures: Percentage of indication- pairs given clinically inconsistent ratings (i.e. higher ratings assigned to one member of an indication-pair when rating should have been equal or lower). Results: In the final round of appropriateness ratings, among 17865 pairs of indications differing only on a single clinical factor (e.g., three- vessel vs. two-vessel stenosis), 6.6% were assigned clinically inconsistent ratings by individual panelists, but only 2.7% received inconsistent ratings from the panel provided fewer inconsistent ratings (4.6%) than either cardiologists (7.8%) or cardiothoracic surgeons (6.3%) (p < 0.001). More inconsistencies were noted when the factor distinguishing otherwise identical indications was symptom severity (inconsistency rate, 13.2%) or intensity of medical therapy (13.2%) than when it was number of stenosed vessels (3.8%) or proximal left anterior descending (PLAD) involvement (1.9%). Contrary to expectations, panelists' inconsistency rates increased between the initial and final rounds of appropriateness ratings (from 3.9 to 6.6%, p < 0.001). Panelists' mean ratings across indications were only weakly correlated with individual inconsistency rates (r = 0.18, p = ns). Conclusions: The RAND/UCLA method for assessing the appropriateness of coronary revascularization generally produces criteria that are clinically consistent. However, research is needed to understand the sources of panelists' inconsistencies and to reduce inconsistency rates further.

Original languageEnglish (US)
Pages (from-to)135-143
Number of pages9
JournalHealth Policy
Issue number2
StatePublished - Nov 1997


  • Clinical consistency
  • Coronary revascularization
  • Expert panels
  • RAND appropriateness method

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Health Policy


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