Appropriate Use Criteria

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Appropriate Use Criteria

• Michael Wolk, M.D., MACC

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The Cost of ImagingMedicare Part B

• 2000-2006, imaging grew 7B to 14B, 13/year vs.
  8 for non-imaging, complex imaging-CT, MR,
  Nuclear, 17/year
• Shift to out-patient 58 to 64
• CV income from imaging rose from 23 to 36
• DRA-OPPS cap in 2007 applied to over 91 of
  CT/MRI, complex imaging costs decreased 12.7,
  despite increased utilization.
• Decrease in 2007 of total imaging expenditures
  from 14B to 12.1 B

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GUIDELINES, PERFORMANCE MEASURES, AND APPROPRIATE
USE CRITERIAWhat are the Differences?

• Clinical Guidelines
• Exhaustive review of literature
• Virtually all-inclusive
• Best practice
• Should do, should not do
• Class I, Class III, Class IIa, IIb
• Performance Measures
• Selective, focused, measurable
• Based on guidelines
• Must do High impact Class Is
• Tools for quality measurement
• Appropriate Use Criteria
• Selective indications
• Largely guideline based
• Clinical scenarios/frequency
• Reasonable to do

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Quality Goals and Action Items In the Dimensions
of Care Framework for Cardiovascular Imaging
Quality Goals Action Items

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Why Appropriateness?

• Significant increase in utilization and cost of
  imaging technology without guideline support
• Substantial regional variation
• True nature of utilization unknown
• Overuse/ Under-use/Abuse
• Clinicians, patients, and especially payers
  seeking guidance
• Unprecedented focus on assessment and improving
  value (quality vs. quantity)

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What are Appropriate Use Criteria?

• Define what to do, when to do, and how
  often to do in the context of local care
  environments combined with patient and family
  preferences and values
• Address misuse and overuse
• Connected to guideline content
• Imply a level of detail and complexity that
  extends beyond the current recommendations

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Appropriate Use CriteriaWhat is an appropriate
imaging test?

• An appropriate imaging study is one in which the
  expected incremental information, combined with
  clinical judgment, exceeds the expected negative
  consequences by a sufficiently wide margin for a
  specific indication that the procedure is
  generally considered acceptable care and a
  reasonable approach for the indication.
• Negative consequences include the risks of the
  procedure (i.e., radiation or contrast exposure)
  and the downstream impact of poor test
  performance such as delay in diagnosis (false
  negatives) or inappropriate diagnosis (false
  positives).

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Appropriate Use Criteria Using the Rand/Delphi
Methodology
Writing Group
Outside Review of Indications and Additional
Modification Prior to Rating
External Reviewers
Balanced panel comprised of different types of
experts rates the indications in two rounds
1st Round No interaction Face-to-Face
Meeting 2nd Round Panel interaction
Appropriateness Determination
Technical Panel
Retrospective comparison with clinical records
Prospective clinical decision aids
Implementation Working Group
Validation
Use that is Appropriate, Uncertain,
Inappropriate
Increase Appropriateness
Adapted from Fitch K, et al. The RAND/UCLA
Appropriateness Method Users Manual, 2001, 4
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Appropriate Use CriteriaThe ACC Queue

• Nuclear cardiology (SPECT)
• October, 2005
• Cardiac CT/CMR
• September, 2006
• Echocardiography
• Summer and Winter 2007
• Coronary Revascularization
• Winter 2008
• Revised SPECT Criteria(Cardiac Radionuclide
  Imaging)
• Multi-Modality Criteria

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Multi-Modality Appropriate Use Criteria

• Potential Scope Multi-modality appropriate use
  criteria will provide a summary of the value of
  using various diagnostic modalities for commonly
  encountered patient scenarios.
• Compared to previously published criteria for
  individual diagnostic testing, this document may
  evaluate how reasonable it is to obtain specific
  types of diagnostic information, compare imaging
  and non-imaging methods, compare invasive and
  non-invasive methods
• Detail when to use or not to use additional
  testing or follow-up testing.
• The writing committee should try to create
  additional information tables on radiation dosage
  and cost/efficiency.

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Multi-Modality AUCProposed Development Process

• Writing committee to review previously published
  AUC documents and consider selecting indications
  for the detection and risk assessment of CAD that
  are
• similar across documents
• frequently encountered
• scenarios for which one or more imaging tests
  and/or no imaging procedures may be a reasonable
  initial strategy over the others
• Add and/modify indications based on updated
  literature, guidelines and/or data
• For the selected indications, consider creating
  rating columns for groups of tests that perform
  similarly, such as
• Stress ECG
• Stress Echo/Nuclear/CMR
• CT Angiography
• Invasive angiography

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Multi-Modality AUCProposed Development Process

• Consider creating additional tables addressing
• Sequential testing/layering of tests -- focusing
  on when additional testing within a relatively
  short time frame may or may not be considered
  after an initial test of another modality
• Serial testing -- focusing on when additional
  testing within a longer time frame may or may not
  be considered, such as additional testing on an
  annual basis
• Relative strengths potentially focus on
  indications for which one or more imaging
  modalities have relative strengths compared to
  others

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Multi-Modality AUCPotential Topics

• Potential Topics
• Detection and risk stratification of patients
  without known CAD
• low-pre-test probability CAD/low CHD risk
• intermediate pre-test probability CAD/moderate
  CHD risk
• Evaluation of new onset/newly diagnosed heart
  failure
• Risk stratification post revascularization
  (Asymptomatic)
• Evaluation of acute chest pain (enzymes negative,
  ECG without changes), intermediate pre-test
  probability of CAD
• Pre-operative assessment
• Evaluation of patients with known CAD and are
  symptomatic

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Multi-Modality AUC Societal Partnerships

• Writing Group, External Reviewers, Technical
  Panel
• ACR
• AHA
• ASE
• ASNC
• SCAI
• SCCT
• SCMR

• Technical Panel, External Reviewers
• AATS
• ACP
• AAFP
• ACCP
• ACEP
• CBNC
• SCCT
• HFSA
• HRS
• IAC
• NASCI
• SAIP
• SCCM
• SIR
• STS
• SVM

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Multi-ModalityWriting Group

• Manuel Cerquiera, MD (ASNC)
• Gregory Dehmer, MD (SCAI)
• Edward Martin, MD (SCMR)
• Michael Picard, MD (ASE)
• Allen Taylor, MD (SCCT)
• Leslee Shaw, Ph.D. (ACC)
• John Spertus, MD, MPH (ACC)
• Manesh Patel, MD (ACC)
• Sid Smith, MD (AHA)
• ACR representative(s) TBD

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Multi-Modality AUCEfficiency/Cost

• Efficiency Advisory Workgroup
• Dr. Eric Peterson (chair), Dr. Joseph Cacchione,
  Dr. Manuel Cerqueira, Dr. Joseph Drozda, Dr. Paul
  Heidenreich, Dr. James Min, Dr. Rita Redberg, Dr.
  Leslee Shaw, Dr. William Weintraub
• To determine whether efficiency can be addressed
  in appropriate use criteria documents and if so,
  in what manner.
• The group will be assigned the responsibility of
  advising the Appropriate Use Criteria Task Force
  on how, if possible, to incorporate cost and
  efficiency considerations more explicitly in
  appropriate use documents.

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Multi-Modality AUCEfficiency Advisory Workgroup
Thoughts

• Important and useful to include information on
  relative costs as part of material to the
  multi-modality reviewers and ultimately in the
  multi-modality document
• That the cost of diagnostic test should not
  limited to pure test charges or inputs (RVUs
  etc) but should also ideally include the
  downstream resources implications of a given
  strategy vs another
• That this is complex and may change depending on
  location, patient characteristics and operator
  quality
• Also important to educate reviewers and readers
  on the complexity of addressing efficiency/cost

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Multi-Modality AUCEfficiency/Cost Considerations

• How is efficiency defined? Cost and Quality?
• What is the definition of cost RVU, Medicare
  rate, private plan reimbursement, practice cost
  to provide service, episode of care.
• What role should specific patient clinical
  characteristics play in efficiency measurement?
• How do expected treatment outcomes (PCI, CABG, or
  medication) contribute to calculating imaging
  efficiency?
• Can efficiency be effectively calculated for
  patient populations that have a wide range of
  risk, such as intermediate risk patients (10 -
  90) prior to the test?
• What is required to calculate comparative
  efficiency?
• What data is currently available that would allow
  us to determine efficiency?

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Thoughts from Audience

• How would you like to see ACC and ACR collaborate
  on the Multi-Modality Appropriate Use Criteria?
  What are your thoughts on ACR Appropriateness
  Criteria?
• Is the proposed MM methodology politically
  doable? Suggested changes to be considered
  ------
• CMS/Payer/RBM Does AUC have value? What changes
  would you like the ACC to consider?
• What are the best methods for implementing and
  testing Multi-Modality Appropriate Use
  Criteria?-Dr. R. Hendel, Chair Implementation
  Subgroup
• Other thoughts, comments, and/or questions?

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Appropriate Use CriteriaExternal Review Process

• Representatives from various societies
• Goal is for reviewers to provide individual and
  societal feedback on the indications early in the
  process
• Purpose of the review is to comment on whether
  the indications clearly articulate typical
  patient scenarios, capture the most common
  patient scenarios, and do not contain large
  sub-populations that may be of differing
  appropriateness for testing. They are NOT to rate
  the indications nor to comment on the
  appropriateness of the indication