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Appropriateness of Appropriateness of Cardiac CareCardiac Care
4/11/20124/11/2012
Paul Heidenreich, MD, MSPaul Heidenreich, MD, MS
Palo Alto VAPalo Alto VA
Relative RelationshipsRelative Relationships
Served on American College of Cardiology Served on American College of Cardiology (ACC) appropriateness rating panel for (ACC) appropriateness rating panel for echocardiographyechocardiography
Currently on writing committee for ACC Currently on writing committee for ACC ICD/CRT appropriateness criteriaICD/CRT appropriateness criteria
Past research grant from MedtronicPast research grant from Medtronic
OutlineOutline
Appropriateness as a measure of qualityAppropriateness as a measure of quality Examples of criteriaExamples of criteria
Echo, Stress TestingEcho, Stress Testing Is US care appropriate?Is US care appropriate?
Echo, ICD, PCIEcho, ICD, PCI Research in Progress: Two Interventions Research in Progress: Two Interventions
to improve appropriatenessto improve appropriateness
Why Appropriateness?Why Appropriateness?
Progressive
Increase in
Office Cardiac Imaging
Levin Health Affairs, 2010
Total
Office
OP Hospital
Need for Appropriateness: 15-fold Need for Appropriateness: 15-fold Variation in Coronary Variation in Coronary Stenting/AngioplastyStenting/Angioplasty
Dartmouth Atlas 2005
CMS Imaging CMS Imaging ReportingReporting
Hospital Compare: CT Hospital Compare: CT ScansScans
Hospitalcompare.hhs.gov
Hospital Compare: Hospital Compare: Follow Up MammogramsFollow Up Mammograms
Hospitalcompare.hhs.gov
Procedure Utilization Procedure Utilization ReviewReview
Prior approachesPrior approaches Review of individual casesReview of individual cases Black box rulesBlack box rules Third party gatekeepersThird party gatekeepers
ACC Survey of ACC Survey of RBM/Prior Authorization RBM/Prior Authorization
PracticePractice
Goals of Appropriateness Goals of Appropriateness MeasuresMeasures
- Create partnerships for rational/fair CV use of procedures Create partnerships for rational/fair CV use of procedures and related reimbursement (clinicians, health plans, and related reimbursement (clinicians, health plans, policymakers and payers)policymakers and payers)
- Educate clinicians on their practice habits Educate clinicians on their practice habits
- Stewardship of health care resourcesStewardship of health care resources
- Improve cost effectiveness of CV procedures (imaging, Improve cost effectiveness of CV procedures (imaging, stenting, devices)stenting, devices)
Understanding Quality in Procedure Understanding Quality in Procedure UtilizationUtilization
UnderuseUnderuse Failure to apply treatment in those Failure to apply treatment in those
likely to benefitlikely to benefit OveruseOveruse
Applying treatment to patients in whom Applying treatment to patients in whom risks risks > > benefitsbenefits
Appropriate Use
Criteria
Guidelines
Rand/UCLA Rating Rand/UCLA Rating MethodMethod
Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method User’s Manual, 2001, 4
Rating of IndicationsRating of Indications
7-9: Appropriate test for specific indication 7-9: Appropriate test for specific indication Test Test isis generally acceptable and generally acceptable and isis a reasonable a reasonable
approach for the indicationapproach for the indication
4-6: Uncertain or unclear if appropriate for specific 4-6: Uncertain or unclear if appropriate for specific indicationindication
Test Test maymay be generally acceptable and be generally acceptable and maymay be a be a reasonable approach for the indication reasonable approach for the indication
1-3: Inappropriate test for specific indication 1-3: Inappropriate test for specific indication Test is Test is notnot generally acceptable and is generally acceptable and is notnot a a
reasonable approach for the indicationreasonable approach for the indication
Uncertain and Uncertain and InappropriateInappropriate
Uncertain does NOT indicate that the procedure Uncertain does NOT indicate that the procedure should NOT be performed for that indication, but should NOT be performed for that indication, but rather more information/research is need to reach rather more information/research is need to reach a firm conclusiona firm conclusion
Uncertain does NOT indicate that the procedure Uncertain does NOT indicate that the procedure should not be reimbursed for that indicationshould not be reimbursed for that indication
Inappropriate rate goal should never be 0%; Inappropriate rate goal should never be 0%; emphasize reduction in patterns of inappropriateemphasize reduction in patterns of inappropriate
AUC and CoverageAUC and Coverage
AUC are not coverage criteria but clinical AUC are not coverage criteria but clinical benchmarking toolsbenchmarking tools
Coverage can be broader and AUC target Coverage can be broader and AUC target clinical nuancesclinical nuances
Registry implementation: potential source of Registry implementation: potential source of information to track usage of procedures after information to track usage of procedures after coverage approvalcoverage approval
AUC DevelopmentAUC DevelopmentCompletedCompleted Nuclear Imaging (SPECT)Nuclear Imaging (SPECT)
October 2005October 2005 Cardiac CT/CMR Cardiac CT/CMR
September 2006September 2006 Echocardiography (TTE, TEE)Echocardiography (TTE, TEE)
July 2007July 2007 Echocardiography (Stress)Echocardiography (Stress)
December 2007December 2007 Coronary RevascularizationCoronary Revascularization
December, 2008December, 2008 Revised Nuclear ImagingRevised Nuclear Imaging May 2009May 2009
Revised CTRevised CT October 2010October 2010 Revised EchocardiographyRevised Echocardiography November 2010November 2010 Revised Coronary RevascularizationRevised Coronary Revascularization January 2012January 2012
In ProgressIn Progress Multi-modality criteriaMulti-modality criteria
Heart failureHeart failureAcute chest painAcute chest pain
Ischemic Heart DiseaseIschemic Heart Disease Vascular Disease UltrasoundVascular Disease Ultrasound Diagnostic CatheterizationDiagnostic CatheterizationICD/CRTICD/CRT
Examples Examples
Revascularization Revascularization PCIPCI
EchoEcho ICDICD
Coronary Coronary RevascularizationRevascularization
Revascularization Revascularization CriteriaCriteria
~200 Clinical scenarios rated by 17 ~200 Clinical scenarios rated by 17 expertsexperts
Based upon the potential benefit to be Based upon the potential benefit to be gained from PCI. Patients’ stratified by…gained from PCI. Patients’ stratified by… Severity of coronary anatomySeverity of coronary anatomy
Magnitude of ischemiaMagnitude of ischemia
Intensity of medical therapyIntensity of medical therapy
Severity of symptomsSeverity of symptoms
STEMISTEMI
Patel, JACC 2009
ACS AlgorithmACS Algorithm
Patel, JACC 2009
Appropriate use criteria for Appropriate use criteria for revascularization help measure revascularization help measure quality… quality…
23
Appropriate Use Appropriate Use of PCIof PCI
Percutaneous Coronary Percutaneous Coronary Intervention (PCI) Intervention (PCI)
RegistryRegistry
Variation in Inappropriate Variation in Inappropriate Use of PCIUse of PCI
Chan JAMA 2011
Volume and Volume and Inappropriate PCIInappropriate PCI
Chan JAMA 2011PCI Procedure VolumeR
ate
of
Inap
pro
pri
ate
PC
I (%
)
R=0.06
CATH-PCI ReportsCATH-PCI Reports
… … and uncover opportunities for cost savings or and uncover opportunities for cost savings or better resource deploymentbetter resource deployment
29
449410
56589
20157
106589
0
100000
200000
300000
400000
500000
600000
700000
2010
Proc
edur
es in
Cat
hPCI
Reg
istry
Not Classifiable
Inappropriate
Uncertain
Appropriate
3.2% of PCI procedures considered inappropriate.
If dropped to
2.2%=44,000,000 USD
Source: Chan et al, internal ACC analysis
ValidatioValidation:n:
AppropriAppropriate ate PCIPCI
Chan, JACC 2011
Validation:Validation:UncertainUncertain
AppropriatenAppropriateness ess
PCIPCI
Chan, JACC 2011
Validation:Validation:InappropriInappropri
ate ate PCIPCI
Chan, JACC 2011
AppropriatAppropriate Use of e Use of
ImplantabImplantable le
DefibrillatDefibrillators ICDors ICD
ICD Use in Primary ICD Use in Primary PreventionPrevention
All-Khatib, JAMA 2011
Rates of Non-Evidence Rates of Non-Evidence Based ICD ImplantationBased ICD Implantation
All-Khatib, JAMA 2011
Individual Reasons for Individual Reasons for Not Meeting GuidelinesNot Meeting Guidelines
All-Khatib, JAMA 2011
Appropriate Use Appropriate Use of Stress Imagingof Stress Imaging
Inappropriate Stress Inappropriate Stress EchoEcho
Douglas, JACC 2008
Appropriateness of Appropriateness of Stress Echo in Valve Stress Echo in Valve
DiseaseDisease
Douglas, JACC 2008
Appropriateness of Appropriateness of Stress ImagingStress Imaging
Gibbons JACC 2008
Inappropriate Stress Inappropriate Stress IndicationsIndications
Gibbons,s JACC 2008
ACCF and United
Healthcare Pilot
INDICATION
% INAPPROPRIATE
INDICATIONS
% TOTAL STUDIES
Detection of CAD. Asymptomatic, low CHD risk 44.5% 6.0%
Asymptomatic, post-revascularization < 2 years after PCI, symptoms before PCI
23.8% 3.2%
Evaluation of chest pain, low probability pt. Interpretable ECG and able to exercise
16.1% 2.2%
Asymptomatic/stable symptoms, known CAD,< 1 year after cath/abnormal SPECT
3.9% 0.5%
Pre-operative assessment. Low risk surgery 3.8% 0.5 %
TOTAL 92.1% 12.4 %
Appropriateness Classification (n=5,928)
Rates same between patients with RBM and without RBM review
Appropriate Use Appropriate Use of of
EchocardiographEchocardiographyy
Inappropriate Echo Inappropriate Echo IndicationsIndications
Rahimi AJC 2011
Inappropriate Inappropriate EchocardiogramsEchocardiograms
Rahimi AJC 2011
Hospital and Provider Hospital and Provider Type:Type:
University of Miami EchoUniversity of Miami Echo
Willens JASE 2009
P<0.05
Inappropriate Inappropriate EchocardiogramsEchocardiograms
Ward, JACC Imaging 2008
Inappropriate Echo Inappropriate Echo ResultsResults
Ward, JACC Imaging 2008Major includes wall motion abnormality, moderate
valve disease, pulmonary HTN, LVEF < 40%, RV dysfunction
Repeat Repeat Echocardiograms: Echocardiograms: Less Appropriate by Less Appropriate by
CriteriaCriteria
Ghatak, Echocardiography 2011
Appropriateness of Appropriateness of Echocardiograms: VA Echocardiograms: VA
Palo AltoPalo Alto
Research PurposeResearch Purpose
To determine if a statement in the To determine if a statement in the echocardiography report can lead to more echocardiography report can lead to more appropriate studies.appropriate studies.
InterventionIntervention
statement in the echo report:statement in the echo report: PositivePositive
Recommended in 2 weeksRecommended in 2 weeks Recommended in 6 monthsRecommended in 6 months Recommended in 1 yearRecommended in 1 year
Negative Negative Not recommended for at least 1 yearNot recommended for at least 1 year Not recommended for at least 3 yearsNot recommended for at least 3 years
Incorporated Into Work Incorporated Into Work FlowFlow
Reader determines if follow-up statement Reader determines if follow-up statement should be addedshould be added
Reporting system randomly includes or Reporting system randomly includes or does not include the statementdoes not include the statement
OutcomeOutcome
Positive statement (follow up Positive statement (follow up recommended by time period X months):recommended by time period X months): Echo within X months -25% to + 50%Echo within X months -25% to + 50%
9 months to 18 months OK for 1 year f/u9 months to 18 months OK for 1 year f/u
Negative statement (follow up not Negative statement (follow up not recommend for at least X monthsrecommend for at least X months Follow-up Echo not done in X months Follow-up Echo not done in X months
Exclusion From Analysis Exclusion From Analysis (if N small)(if N small)
Echo performed for new indicationEcho performed for new indication Patient leaves the Palo Alto VA health Patient leaves the Palo Alto VA health
care system before follow-up periodcare system before follow-up period DeathDeath Changed health systemsChanged health systems
AnalysisAnalysis
Primary: first echocardiogram per patientPrimary: first echocardiogram per patient Secondary: multiple echocardiograms per Secondary: multiple echocardiograms per
patientpatient
ProgressProgress
Study Initiated 7/2012Study Initiated 7/2012 1032 reports randomized 50:501032 reports randomized 50:50
989 unique patients989 unique patients 849 negative recommendations849 negative recommendations 183 positive recommendations183 positive recommendations
Follow Up StudiesFollow Up Studies
Follow-Up Studies after a Follow-Up Studies after a Negative Negative
RecommendationRecommendation 41 echo requests examined 41 echo requests examined
9 clearly inappropriate9 clearly inappropriate Plan to enroll until we have 100 Plan to enroll until we have 100
inappropriate follow-up echocardiogramsinappropriate follow-up echocardiograms
Left Left VentriculographyVentriculography
Test is not “ordered”.Test is not “ordered”. Decision made by the invasive cardiologist Decision made by the invasive cardiologist
at the time of coronary angiography.at the time of coronary angiography. Adds contrast (small risk of worsening Adds contrast (small risk of worsening
renal function)renal function) Adds radiation (minimal risk of cancer)Adds radiation (minimal risk of cancer)
Use ofUse ofLeft VentriculographyLeft Ventriculography
Use during coronary angiographyUse during coronary angiography >80% among Aetna patients despite >80% among Aetna patients despite
recent echocardiogramrecent echocardiogram Does the rate vary across facilities?Does the rate vary across facilities?
Appropriateness Appropriateness Left VentriculographyLeft Ventriculography
Witteles, AHJ 2012
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Left
Ven
tric
ulo
grap
hy
Du
rin
g C
oro
nar
y A
ngi
ogr
aph
y
Individual VA Hospitals
Variation in LVgram UseVariation in LVgram Use
LV Gram LV Gram Appropriateness Appropriateness
InterventionIntervention 1) Have VA providers of left 1) Have VA providers of left
ventriculography (invasive cardiologists) ventriculography (invasive cardiologists) rate appropriateness of different rate appropriateness of different scenarios.scenarios.
LV Gram LV Gram Appropriateness Appropriateness
InterventionIntervention 2) Determine appropriateness using the 2) Determine appropriateness using the
VA’s national catheterization laboratory VA’s national catheterization laboratory reporting systemreporting system
LV Gram LV Gram Appropriateness Appropriateness
InterventionIntervention 3) Feedback performance to each VA 3) Feedback performance to each VA
laboratory.laboratory.
Progress?Progress?
Appropriateness of EchoAppropriateness of Echo
Rahimi AJC 2011
Nuclear Medicine UseNuclear Medicine Use
Levin Health Affairs, 2010