<International Circulation>: A lot of work has been done by yourself and others on selection criteria for coronary revascularization procedures. What are the basic principles involved?

    Dr Spertus: If we think about what we have tried to do over the years to understand quality in the delivery of health care， particularly angioplasty， we have largely focused on where there has been some evidence of benefit， and have we complied with current Guidelines and recommendations for the conduct of the procedure. There has been very little effort to try to look at and better understand the selection process that we do as clinicians in identifying which patients benefit most， or not， from a procedure. Recently， the Appropriate Use Criteria were developed as an extension of the Guidelines to try and help us understand which patients derive the greatest benefit from the procedures and， conversely， in which patients the risks might exceed the benefits. If the risks exceed the benefit， then doing a procedure in a patient with very little to benefit might represent overuse of the procedure. On the other hand， if there are patients we are not offering the procedure to – and who would stand to benefit greatly from revascularization – that would represent underuse. In developing the Appropriate Use Criteria， the ACC fundamentally broke down what are the expected survival advantages of revascularization and what are the expected quality of life advantages of revascularization for almost two hundred scenarios. Using those criteria， as manifest by the severity of the coronary anatomy and ischemia as a means of quantifying survival advantages from revascularization， and the extent of angina and the intensity of medical therapy as a way of looking at the quality of life advantages of angioplasty and bypass surgery， they graded almost two hundred scenarios along a scale of 1 to 9 with the lowest three choices being an inappropriate procedure， the middle three choices being uncertain and the top choices representing an appropriate procedure. In the United States right now， we are systematically measuring this at all 1200 participating centers in the American College of Cardiology National Cardiovascular Data Registry. This will enable us to measure the strength of the indications for each patient that is treated with angioplasty in the hope we can gain new insights into the decision-making process and learn from each other what proportion of our patients would be deemed inappropriate， uncertain or appropriate for their procedure.