Measuring and governing potentially low-value invasive coronary angiography in Europe: a systematic review, construct-specific meta-analysis, and policy framework.

In 30 seconds

This PRISMA 2020 systematic review and construct-specific random-effects meta-analysis examined indicators used to measure potentially low-value invasive coronary angiography in European health systems. Thirty reports were mapped, with 13 studies contributing 14 estimates; primary analyses covered 30,952 procedures in eight countries. Pooled values differed substantially by indicator: 8.4% (95% CI 2.1-28.3) for formal appropriateness adjudication, 58.2% (24.9-85.4) for guideline-discordant pathways and 42.6% (33.1-52.7) for low diagnostic yield. Extreme heterogeneity means these are construct-dependent signals, not estimates of Europe-wide unnecessary angiography.

Key findings

• Pooled formal appropriateness adjudication classified 8.4% (95% CI 2.1-28.3) of procedures as potentially low-value.
• The pooled value was 58.2% (24.9-85.4) for guideline-discordant referral pathways and 42.6% (33.1-52.7) for low diagnostic yield.
• Heterogeneity was extreme; two constructs had only two studies, and Knapp-Hartung intervals spanned essentially the full proportion scale.
• The review proposes harmonised data, construct-specific indicators, record validation and monitoring for unintended underuse before benchmarking or payment-based use.

Why it matters

Different indicators identify different potential governance problems and produce markedly different estimates. Treating them as interchangeable could misrepresent the extent of unnecessary angiography or encourage reductions that result in underuse. The review highlights the need to validate what each measure captures before using it to compare services or guide policy.

What to keep in mind

Evidence was highly heterogeneous, and two constructs included only two studies. The proposed policy framework was author-derived and was not evaluated by the review.