Coronary CT Angiography: Quality Assurance Oct 2006

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Coronary CT Angiography Quality Assurance Oct
2006

• Gilbert L. Raff, MD
• Director, Ministrelli Center for
• Advanced Cardiovascular Imaging
• William Beaumont Hospital
• Royal Oak, MI

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Overview

• 64-slice CT scanners are highly accurate (85-90)
  when compared to invasive angiography, but there
  are limitations.
• The high negative predictive accuracy (over 90)
  suggests applications in excluding CAD
• acute chest evaluation
• equivocal treadmill evaluation, and certain other
  uses.
• However, proof of clinical effectiveness studies
  are just emerging. I will discuss two.
• Is CTA just an added cost, or will it improve
  care and be cost-effective?
• The Advanced Cardiovascular Imaging Consortium
  was initiated by Blue Cross USA to define
  clinical value and quality assurance in the
  optimal use of CTA.

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With Images Like These It Must Be Accurate, Right?

• Raff et al. JACC (2005) v 46, pg 552

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Accuracy from Meta-AnalysisHoffman et al. MGH in
press

• 42 studies, Random Effects model
• 64-slice CTA
• Per Patient, DOR 697
• Sensitivity 98 corresponds to Specifity of 92
• 16-slice CTA
• Per Patient, DOR 442
• Sensitivity 99 corresponds to Specifity of 83

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Challenges
16
64

• Reconstruction artifacts Calcium score
  1100

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Diagnostic Accuracy of Noninvasive Coronary
Angiography Using 64-Slice Spiral CT

• Raff et al. JACC (2005) v 46, pg 552
• Quantitative accuracy /- 25

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64 STAT study algorithm
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MSCT Coronary AngiographyLeft main and proximal
LAD soft plaque
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Results 64 STAT study

• 75 of patients in the CTA group had immediate
  disposition based on the test.
• Immediate discharge 67 patients were normal.
  None had adverse event in 6 months.
• 8 patients had immediate cath. 7/8 had
  significant CAD.
• 25 required stress testing
• 11 had unreadable scans in at least one segment
• 14 had intermediate grade lesions.

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Results Cost-effectiveness

• Length of stay, CTA vs Standard group reduced
  by 77
• 3.4 vs 15.0 hours, p lt 0.001
• Cost of care, CTA vs Standard group reduced by
  15
• 1,586 vs 1,872, p lt 0.001

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IMPACCT Treadmill study

• 200 patients with chest pain in outpatient
  setting
• Indications for CTA
• Equivocal stress test
• Positive test with low probability
• Negative test with high probability
• Physicians asked to classify pretest management
  in absence of CTA results
• Definitely would cath
• Another non-invasive test
• Medical therapy
• Nothing
• Post CTA followed for 3 months

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IMPACCT prelim results

• Before CTA, physicians planned to cath
• 65 to date 107/165
• Actual caths after CTAs
• 19 to date 31/165
• Cost-savings to date
• Caths reduced by 71 at this point.

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The Creation of ACIC

• David Share, MD, MPH, Clinical Director, Center
  for Health Care Quality, Sandy Reoma, Project
  Manager, PPO Programs, BCBS/BCN
• Executive Committee charged with developing
  clinical standards, database and reports.
• Gil Raff, MD PI, Director cardiac CT/MRI
  Beaumont
• Ella Kazerooni, MD director Thoracic Radiology,
  U of M
• Mauro Moscucci, MD PI of BCM2 CQI
• Tauqir Goraya, MD Director CT/MR Mich Heart Grp
• Aiden Abidov, MD, PhD Clinical investigator,
  WBH
• Lorelei Grines, PhD Director of Coordinating
  Center charged with implementation and
  management of registry.
• Karen Raff, BSN Jan Parslow, BSN research
  coordinators

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ACIC Structure

• Coordinating center
• Protocol and database design
• Research coordinators
• Training
• Audits
• Reporting
• Profiles
• Quarterly meetings
• Participating sites
• Clinical Champion
• Research coordinator
• Technologists
• Interpreting MDs

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ACIC Registry

• Data collection
• Indications for procedure MD based information
• Symptoms medical history pt based/office
  based/hospital based
• CTA test results/technical information
• 90 day followup
• Subsequent procedures
• Subsequent medical events
• Reporting
• Quarterly meetings
• ACIC group outcomes
• Direct reports to participating sites

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Clinical Scenarios

• Patients with normal CTAs
• Expect few subsequent tests
• Expect few clinical events
• Severely abnormal CTAs
• Expect high cath numbers
• Expect high revasc numbers
• Intermediate severity CTAs
• Expect further non-invasive tests

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ACIC Summary

• BCBSM/BCN and the ACIC consortium would like to
  initiate coverage of CTA with a collaborative
  quality initiative.
• We believe coronary CTA is an accurate and
  cost-effective technology when used
  appropriately.
• ACIC will roll out initially to selected
  BCBSM/BCN participating hospitals.