Appropriateness of Cardiac Care

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Appropriateness of Cardiac Care

• 4/11/2012
• Paul Heidenreich, MD, MS
• Palo Alto VA

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Relative Relationships

• Served on American College of Cardiology (ACC)
  appropriateness rating panel for echocardiography
• Currently on writing committee for ACC ICD/CRT
  appropriateness criteria
• Past research grant from Medtronic

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Outline

• Appropriateness as a measure of quality
• Examples of criteria
• Echo, Stress Testing
• Is US care appropriate?
• Echo, ICD, PCI
• Research in Progress Two Interventions to
  improve appropriateness

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Why Appropriateness?
Progressive Increase in Office Cardiac Imaging
Total
Office
OP Hospital
Levin Health Affairs, 2010
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Need for Appropriateness 15-fold Variation in
Coronary Stenting/Angioplasty
Dartmouth Atlas 2005
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CMS Imaging Reporting
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Hospital Compare CT Scans
Hospitalcompare.hhs.gov
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Hospital Compare Follow Up Mammograms
Hospitalcompare.hhs.gov
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Procedure Utilization Review

• Prior approaches
• Review of individual cases
• Black box rules
• Third party gatekeepers

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ACC Survey of RBM/Prior Authorization Practice
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Goals of Appropriateness Measures

• Create partnerships for rational/fair CV use of
  procedures and related reimbursement (clinicians,
  health plans, policymakers and payers)
• Educate clinicians on their practice habits
• Stewardship of health care resources
• Improve cost effectiveness of CV procedures
  (imaging, stenting, devices)

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Understanding Quality in Procedure Utilization

• Underuse
• Failure to apply treatment in those likely to
  benefit
• Overuse
• Applying treatment to patients in whom risks gt
  benefits

Guidelines
Appropriate Use Criteria
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Rand/UCLA Rating Method
Adapted from Fitch K, et al. The RAND/UCLA
Appropriateness Method Users Manual, 2001, 4
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Rating of Indications

• 7-9 Appropriate test for specific indication
• Test is generally acceptable and is a reasonable
  approach for the indication
• 4-6 Uncertain or unclear if appropriate for
  specific indication
• Test may be generally acceptable and may be a
  reasonable approach for the indication
• 1-3 Inappropriate test for specific indication
• Test is not generally acceptable and is not a
  reasonable approach for the indication

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Uncertain and Inappropriate

• Uncertain does NOT indicate that the procedure
  should NOT be performed for that indication, but
  rather more information/research is need to reach
  a firm conclusion
• Uncertain does NOT indicate that the procedure
  should not be reimbursed for that indication
• Inappropriate rate goal should never be 0
  emphasize reduction in patterns of inappropriate

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AUC and Coverage

• AUC are not coverage criteria but clinical
  benchmarking tools
• Coverage can be broader and AUC target clinical
  nuances
• Registry implementation potential source of
  information to track usage of procedures after
  coverage approval

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AUC Development

• Completed
• Nuclear Imaging (SPECT)
• October 2005
• Cardiac CT/CMR
• September 2006
• Echocardiography (TTE, TEE)
• July 2007
• Echocardiography (Stress)
• December 2007
• Coronary Revascularization
• December, 2008
• Revised Nuclear Imaging
• May 2009

• Revised CT
• October 2010
• Revised Echocardiography
• November 2010
• Revised Coronary Revascularization
• January 2012
• In Progress
• Multi-modality criteria
• Heart failure
• Acute chest pain
• Ischemic Heart Disease
• Vascular Disease Ultrasound
• Diagnostic Catheterization
• ICD/CRT

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Examples

• Revascularization
• PCI
• Echo
• ICD

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Coronary Revascularization
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Revascularization Criteria

• 200 Clinical scenarios rated by 17 experts
• Based upon the potential benefit to be gained
  from PCI. Patients stratified by
• Severity of coronary anatomy
• Magnitude of ischemia
• Intensity of medical therapy
• Severity of symptoms

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STEMI
Patel, JACC 2009
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ACS Algorithm
Patel, JACC 2009
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Appropriate use criteria for revascularization
help measure quality
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Appropriate Use of PCI
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Percutaneous Coronary Intervention (PCI) Registry
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Variation in Inappropriate Use of PCI
Chan JAMA 2011
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Volume and Inappropriate PCI
R0.06
Rate of Inappropriate PCI ()
PCI Procedure Volume
Chan JAMA 2011
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CATH-PCI Reports
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and uncover opportunities for cost savings or
better resource deployment
3.2 of PCI procedures considered
inappropriate. If dropped to 2.2 44,000,000 USD
Source Chan et al, internal ACC analysis
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ValidationAppropriate PCI
Chan, JACC 2011
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ValidationUncertainAppropriateness PCI
Chan, JACC 2011
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ValidationInappropriate PCI
Chan, JACC 2011
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Appropriate Use of Implantable Defibrillators ICD
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ICD Use in Primary Prevention
All-Khatib, JAMA 2011
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Rates of Non-Evidence Based ICD Implantation
All-Khatib, JAMA 2011
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Individual Reasons for Not Meeting Guidelines
All-Khatib, JAMA 2011
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Appropriate Use of Stress Imaging
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Inappropriate Stress Echo
Douglas, JACC 2008
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Appropriateness of Stress Echo in Valve Disease
Douglas, JACC 2008
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Appropriateness of Stress Imaging
Gibbons JACC 2008
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Inappropriate Stress Indications
Gibbons,s JACC 2008
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ACCF and United Healthcare
Pilot
Appropriateness Classification (n5,928)
INDICATION INAPPROPRIATE INDICATIONS TOTAL STUDIES
Detection of CAD. Asymptomatic, low CHD risk 44.5 6.0
Asymptomatic, post-revascularization lt 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,lt 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
Rates same between patients with RBM and without
RBM review
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Appropriate Use of Echocardiography
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Inappropriate Echo Indications
Rahimi AJC 2011
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Inappropriate Echocardiograms
Rahimi AJC 2011
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Hospital and Provider TypeUniversity of Miami
Echo
Plt0.05
Willens JASE 2009
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Inappropriate Echocardiograms
Ward, JACC Imaging 2008
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Inappropriate Echo Results
Major includes wall motion abnormality, moderate
valve disease, pulmonary HTN, LVEF lt 40, RV
dysfunction
Ward, JACC Imaging 2008
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Repeat Echocardiograms Less Appropriate by
Criteria
Ghatak, Echocardiography 2011
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Appropriateness of Echocardiograms VA Palo Alto
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Research Purpose

• To determine if a statement in the
  echocardiography report can lead to more
  appropriate studies.

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Intervention

• statement in the echo report
• Positive
• Recommended in 2 weeks
• Recommended in 6 months
• Recommended in 1 year
• Negative
• Not recommended for at least 1 year
• Not recommended for at least 3 years

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Incorporated Into Work Flow

• Reader determines if follow-up statement should
  be added
• Reporting system randomly includes or does not
  include the statement

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Outcome

• Positive statement (follow up recommended by time
  period X months)
• Echo within X months -25 to 50
• 9 months to 18 months OK for 1 year f/u
• Negative statement (follow up not recommend for
  at least X months
• Follow-up Echo not done in X months

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Exclusion From Analysis (if N small)

• Echo performed for new indication
• Patient leaves the Palo Alto VA health care
  system before follow-up period
• Death
• Changed health systems

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Analysis

• Primary first echocardiogram per patient
• Secondary multiple echocardiograms per patient

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Progress

• Study Initiated 7/2012
• 1032 reports randomized 5050
• 989 unique patients
• 849 negative recommendations
• 183 positive recommendations

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Follow Up Studies
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Follow-Up Studies after a Negative Recommendation

• 41 echo requests examined
• 9 clearly inappropriate
• Plan to enroll until we have 100 inappropriate
  follow-up echocardiograms

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Left Ventriculography
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Use ofLeft Ventriculography

• Test is not ordered.
• Decision made by the invasive cardiologist at the
  time of coronary angiography.
• Adds contrast (small risk of worsening renal
  function)
• Adds radiation (minimal risk of cancer)

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Appropriateness Left Ventriculography

• Use during coronary angiography
• gt80 among Aetna patients despite recent
  echocardiogram
• Does the rate vary across facilities?

Witteles, AHJ 2012
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Variation in LVgram Use
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LV Gram Appropriateness Intervention

• 1) Have VA providers of left ventriculography
  (invasive cardiologists) rate appropriateness of
  different scenarios.

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LV Gram Appropriateness Intervention

• 2) Determine appropriateness using the VAs
  national catheterization laboratory reporting
  system

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LV Gram Appropriateness Intervention

• 3) Feedback performance to each VA laboratory.

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Progress?
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Appropriateness of Echo
Rahimi AJC 2011
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Nuclear Medicine Use
Levin Health Affairs, 2010