Appropriateness of
Cardiac Care
4/11/2012
Paul Heidenreich, MD, MS
Palo Alto VA
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
Outline


Appropriateness as a measure of quality
Examples of criteria


Is US care appropriate?


Echo, Stress Testing
Echo, ICD, PCI
Research in Progress: Two Interventions
to improve appropriateness
Why Appropriateness?
Total
Office
Progressive
Increase in
Office
Cardiac
Imaging
OP Hospital
Levin Health Affairs, 2010
Need for Appropriateness: 15-fold Variation in
Coronary Stenting/Angioplasty
Dartmouth Atlas 2005
CMS Imaging
Reporting
Hospital Compare: CT Scans
Hospitalcompare.hhs.gov
Hospital Compare: Follow Up
Mammograms
Hospitalcompare.hhs.gov
Procedure Utilization Review

Prior approaches
 Review of individual cases
 Black box rules
 Third party gatekeepers
ACC Survey of
RBM/Prior Authorization Practice
Ability of referring physicians to place orders
56%
Educational benefit of interaction
Physician selection of test without forced test
substitution
92%
61%
Transparency in decisions
72%
Accuracy in review of clinical decision making
Timeliness and avoiding clinical delay
69%
56%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
Poor or Very Poor Performance
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)
Understanding Quality in Procedure Utilization


Underuse
 Failure to apply treatment in those
likely to benefit
Overuse
 Applying treatment to patients in whom
risks > benefits
Guidelines
Appropriate
Use Criteria
Rand/UCLA Rating Method
Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method User’s Manual, 2001, 4
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
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
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
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
Examples

Revascularization



PCI
Echo
ICD
Coronary Revascularization
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
STEMI
Patel, JACC 2009
ACS Algorithm
Patel, JACC 2009
Appropriate use criteria for revascularization
help measure quality…
23
Appropriate Use of
PCI
Percutaneous Coronary
Intervention (PCI) Registry
Variation in Inappropriate Use of PCI
Chan JAMA 2011
Rate of Inappropriate PCI (%)
Volume and Inappropriate PCI
R=0.06
PCI Procedure Volume
Chan JAMA 2011
CATH-PCI Reports
… and uncover opportunities for cost savings or
better resource deployment
700000
Procedures in CathPCI Registry
600000
500000
106589
20157
56589
Not Classifiable
Inappropriate
400000
Uncertain
300000
Appropriate
200000
3.2% of PCI procedures
considered inappropriate.
If dropped to
2.2%=
44,000,000 USD
449410
100000
0
2010
Source: Chan et al, internal ACC analysis
29
Validation:
Appropriate
PCI
Chan, JACC 2011
Validation:
Uncertain
Appropriateness
PCI
Chan, JACC 2011
Validation:
Inappropriate
PCI
Chan, JACC 2011
Appropriate
Use of
Implantable
Defibrillators
ICD
ICD Use in Primary Prevention
All-Khatib, JAMA 2011
Rates of Non-Evidence Based
ICD Implantation
All-Khatib, JAMA 2011
Individual Reasons for Not
Meeting Guidelines
All-Khatib, JAMA 2011
Appropriate Use of
Stress Imaging
Inappropriate Stress Echo
Douglas, JACC 2008
Appropriateness of Stress Echo in
Valve Disease
Douglas, JACC 2008
Appropriateness of Stress
Imaging
Gibbons JACC 2008
Inappropriate Stress Indications
Gibbons,s JACC 2008
Appropriateness Classification (n=5,928)
ACCF and
United Healthcare
Pilot
%
INAPPROPRIATE
INDICATIONS
% TOTAL
STUDIES
44.5%
6.0%
Asymptomatic, postrevascularization < 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 %
INDICATION
Detection of CAD. Asymptomatic,
low CHD risk
Rates same between patients with RBM and
without RBM review
Appropriate Use of
Echocardiography
Inappropriate Echo Indications
Rahimi AJC 2011
Inappropriate Echocardiograms
Rahimi AJC 2011
Hospital and Provider Type:
University of Miami Echo
P<0.05
Willens JASE 2009
Inappropriate Echocardiograms
Ward, JACC Imaging 2008
Inappropriate Echo Results
Major includes wall motion abnormality, moderate valve disease,
Ward, JACC Imaging 2008
pulmonary HTN, LVEF < 40%, RV dysfunction
Repeat Echocardiograms:
Less Appropriate by Criteria
Ghatak, Echocardiography 2011
Appropriateness of
Echocardiograms: VA Palo Alto
Research Purpose

To determine if a statement in the
echocardiography report can lead to more
appropriate studies.
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

Incorporated Into Work Flow


Reader determines if follow-up statement
should be added
Reporting system randomly includes or
does not include the statement
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
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

Analysis


Primary: first echocardiogram per patient
Secondary: multiple echocardiograms per
patient
Progress


Study Initiated 7/2012
1032 reports randomized 50:50



989 unique patients
849 negative recommendations
183 positive recommendations
Follow Up Studies
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
Left Ventriculography
Use of
Left 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)
Appropriateness
Left Ventriculography



Use during coronary angiography
>80% among Aetna patients despite
recent echocardiogram
Does the rate vary across facilities?
Witteles, AHJ 2012
Variation in LVgram Use
Left Ventriculography During Coronary
Angiography
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Individual VA Hospitals
LV Gram Appropriateness
Intervention

1) Have VA providers of left
ventriculography (invasive cardiologists)
rate appropriateness of different
scenarios.
LV Gram Appropriateness
Intervention

2) Determine appropriateness using the
VA’s national catheterization laboratory
reporting system
LV Gram Appropriateness
Intervention

3) Feedback performance to each VA
laboratory.
Progress?
Appropriateness of Echo
Rahimi AJC 2011
Nuclear Medicine Use
Levin Health Affairs, 2010