Interventional Cardiology and Cath Labs
Has AUC Changed Our Practice?
Manesh R. Patel, MD
Director of Interventional Cardiology
Duke University Health System
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Interventional Cardiology and Cath Labs
Disclosures
• Interventional cardiologist
• Research Grants:
– NHLB, AHRQ, AstraZeneca, Pleuristem, Johnson and Johnson,
Maquet / Datascope
• Advisory Board/Consulting:
– Genzyme, Bayer, Baxter Healthcare, Ortho McNeil Jansen,
theHeart.org, Medscape, Maquet, CSI technologies
• Professional Society Roles:
– Member ACC/AHA AUC Task Force
– Chair of Writing Group for ACC/AHA Coronary Revascularization
Appropriateness Criteria
– Chair of AHA Diagnostic and Interventional Cath Committee
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Interventional Cardiology and Cath Labs
Has AUC changed our practice
• What was the state of cardiovascular
practice before the AUC?
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Imaging Use
Dollars (billions)

Medicare spending on imaging services more
than doubled from 2000 through 2006
13% annual growth
Source: GAO Analysis of Medicare
Data, Report GAO-08-452.
GR-2012-MP
What is the Evidence Base
in Imaging?
ACC/AHA Guidelines
Class I
Class II a
Class II b
Class III
Level 1: 1%
III: 18%
Level 2: 45%
I: 51%
IIb:
18%
Level1
IIa: 13%
745
Recommendations
Level 3: 54%
‘Strength’ of
the evidence
Level 2
Level 3
How do we currently perform – predicting
obstructive coronary disease?
• 38% Stenoses ≥50% LM
or ≥ 70% epicardial
• 41% by any ≥ 50%
• 39% had all stenoses
<20%
GR-2012-MP
Value of pre-angiography information
P redictin g Obstructive CAD: Mod el Performan ce
0.78
0.76
0. 761
0. 764
Model 3:
M odel2+ Sx.
Model 4:
Model3+S tres s Test
0. 742
0.74
0.72
c-statistic
0.7
0.68
0.67
0.66
0.64
0.62
Model 1:
Framing S core
Model 2:
Model 1+ Cl ini cal
V ariables
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Interventional Cardiology and Cath Labs
Variation in procedures
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Call for Appropriateness Evaluation

Explosive growth of CV imaging

Substantial regional variation

True nature of utilization unknown
 Overuse/ Underuse/Appropriate

New imaging methods on the horizon
 Further accentuate the need for criteria

Clinicians, patients, and especially payers
seeking guidance
GR-2012-MP
GR-2012-MP
Development of CPG’s, Performance
Measures, and Appropriate Use Documents
Antman, Circulation 2009:119:1180-1185.
The Writing
Committee
Define “Appropriateness”
for Coronary Revascularization
“Coronary revascularization is appropriate when the expected
benefits, in terms of survival or health outcomes (symptoms,
functional status, and/or quality of life) exceed the expected
negative consequences of the procedure”
AUC Terminology
• Based on published RAND/UCLA documents.
• Appropriate does not mean mandatory
• procedure is generally acceptable and is generally reasonable for
the indication).
• May be Appropriate * does not mean inappropriate or
questionable and is reimbursable
• procedure may be acceptable and may be reasonable for the
indication)
• Rarely Appropriate does not mean fraud?deceit ?
Goal is not 0%, however, a consistent inappropriate patterns
should be reviewed by physician practices
i.e., procedure is not generally acceptable and is not
generally reasonable for the indication).
21 AUC documents over 9 years (2.33 / year)
Figure 1 Timeline of ACCF AUC Development, Including Current Pipeline of Documents in Development ACCF = American
College of Cardiology Foundation; ACR = American College of Radiology; CT = computed tomography; Dx Cath = diagnostic
catheterizati...
Appropriate Use of Cardiovascular Technology : 2013 ACCF Appropriate Use Criteria Methodology Update
Journal of the American College of Cardiology null 2013 null
http://dx.doi.org/10.1016/j.jacc.2013.01.025
Interventional Cardiology and Cath Labs
Has AUC Changed Non-Invasive Practice?
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Prospective study with AUC
used on SPECT practice
with feedback
AUC for SPECT improved
prognostication
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ACC Focus Tool for
Non-invasive
imaging
Delaware NIT preauthorization
moved from prior
methods to AUC
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AUC for Coronary Revascularization
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Measuring Appropriateness
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Interventional Cardiology and Cath Labs
Hospital variation in non-acute PCI - inappropriate rates
Chan PS et al. JAMA 2011;306:53-61
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Retrospective Cohort Confirmation of
Outcomes with AUC for Revascularization
22
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Interventional Cardiology and Cath Labs
Studies on Appropriate Use Criteria
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Interventional Cardiology and Cath Labs
Has AUC changed outcomes?
• Yes AUC have lead to change in practice
• Question is are these changes in practice
improving patient outcomes or care
processes a
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Interventional Cardiology and Cath Labs
AUC
• Where are we going?
– Are we the only ones doing AUC
– What should we measure to improve care in
patients undergoing chest pain and possible
angiography and revascularization
(percutaneous)
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Interventional Cardiology and Cath Labs
Thought Experiment……?
Cardiovascular Practice
2006
• Widespread variation
• Increasing costs
• Pre-authorization
without standard criteria
for non-invasive imaging
• Diagnostic rates of tests
and outcome rates of
procedures not
evaluated in
standardized fashion
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If the AUC did not exist ..
Would there be metrics put in
place to measure practice?
Who and how would it be
done?
Why is Cardiology only doing AUC?
“If I have a knee pain and want it treated for quality of
life I can get it done…… that is my preference” Gregg
Stone
APPROPRIATE USE CRITERIA
FOR NON-ARTHROPLASTY TREATMENT
OF OSTEOARTHRITIS OF THE KNEE
Adopted by the American Academy of Orthopaedic Surgeons
Board of Directors
12-06-13
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% of Total Ratings
be found under each of the five treatment columns. These crit
appropriateness labels (i.e. “R”=Rarely Appropriate, “M”=May
“A”=Appropriate), median score (in parentheses), and + or - in
disagreement amongst the voting panel, respectively.
20%
13%
15%
14%
13%
9%
APPROPRIATE USE CRITERIA
FOR
9%
10%
OPTIMIZING THE MANAGEMENT OF 5%
FULL-THICKNESS
ROTATOR CUFF
5%
TEARS
8%
We are not the only
ones doing AUC
2%
0%
1
2
3
4
5
6
7
Out of 2160 total voting items (i.e. 432 patient scenarios x 5 treatmen
items were rated as “Rarely Appropriate”, 677 (31%) voting items w
Appropriate”, and 335 (16%) voting items were rated as “Appropriate”
Additionally, the voting panel members were in agreement on 1238 (57%
in disagreement on 2 (0.09%) voting items (see Figure 4 for within tre
two items that the voting panel disagreed on were repair treatment for
For a within treatment breakdown of appropriateness ratings, please refer
8
9
Adopted by the American Academy of Orthopaedic Surgeons
Voting Panel Median Appropriatness Rating
Board of Directors
FIGURE 1. BREAKDOWN OF APPROPRIATENESS RATINGS
September 20, 2013
Appropriate
Treatments
16%
FIGURE 3. WITHIN TREATMENT APPROPRIATENESS RATINGS
Rarely Appropriate
May Be Appropriate
Appropriate
98%
Rarely
Appropriate
Treatments
53%
100%
85%
90%
80%
69%
% of Ratings
70%
53%
60%
50%
52%
46%
40%
31%
31%
30%
17%
20%
10%
1%
1%
15%
0%
2%
0%
0%
Non-operative
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Partial Repair
and/or
Repair
Reconstruct
Arthroplasty
May Be
Appropriate
Treatments
31%
29
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The possibly change……
Likely to occur and you should be measuring your
practice….. Appropriateness being pushed upstream
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Interventional Cardiology and Cath Labs
“What this patients needs ….. Is a doctor”
Doctors need to
follow their
patients to
determine how
they will do…
“Prognostogram”
to see how
patients will do
with therapy
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Lesson # 5 - The Hope - Dr. Stead’s vision brought forward
EHR or User Input
•Enter Patient Data
•Symptom Data
•Non-invasive findings
•Mark Coronary Tree
•Measured Pressures (FFR)
Patient Input:
•General Ideas of Choices
Output :
1.Guideline and AUC criteria
2.Syntax Risk Score
3.PCI – ACC/NCDR Risk Score
4.STS Risk Score
5.Bleeding Risk
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Heart Team review cloud
Hospital uploads images/data
(Outside and internal sources)
Available to clinic MD on
review when seeing pt.
Low-cost cloud storage
Open-source PACS server
Network Hospitals “on-star” real
time consultation / peer review
DICOM viewer
Image adjudication
Interventional
cardiology
CT Surgery
Reviewer
Quality control analytics
Customer and/or
end-user
Customer and/or
end-user
Peer Review Status
MOC
High Quality Cardiovascular Procedures
Quality Metrics
Public Reporting
Patient Preferences
Right
Patient
Right
Procedure
Decision
Appropriate Use Criteria
Guidelines
Right Procedure
Execution
Ongoing trials
and evidence
Right
Outcome
Performance Measures
Value equation for cardiovascular procedures – was the
right procedure done in the right way with the right outcome
in a timely fashion? Measures (AUC / Outcome Measures)
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Interventional Cardiology and Cath Labs
Conclusions
• AUC update for revascularization this year
– FFR – physiology, Independent assessment of
Anti-Anginal Therapy, PCI, CABG
– Transplant, staged procedures, non-IRA,
TAVR-PRCI
• Digital Clinical decision support tools
• Practice is changing
– Still need to measure if improvement has
occurred
– Worth realizing rarely appropriate patients
(usually have less CAD and better outcomes)
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Interventional Cardiology and Cath Labs
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“We are what we repeatedly do……. Excellence then is
a habit and not an act. Aristotle”
Are you keeping your pre-cath patients NPO?
How do you schedule your cath patients? Do you have same day discharge?
Does everyone get 90 days of P2Y12 inhibitor?
Do you have her images reviewed by all that need to?
- Marcel Proust
Variation in Care
PCI Rates per 1,000 Medicare Enrollees (2002-03)
http://www.dartmouthatlas.org/
GR-2012-MP