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Appropriateness of Cardiac Care

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Title: Appropriateness of Cardiac Care


1
Appropriateness of Cardiac Care
  • 4/11/2012
  • Paul Heidenreich, MD, MS
  • Palo Alto VA

2
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

3
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

4
Why Appropriateness?
Progressive Increase in Office Cardiac Imaging
Total
Office
OP Hospital
Levin Health Affairs, 2010
5
Need for Appropriateness 15-fold Variation in
Coronary Stenting/Angioplasty
Dartmouth Atlas 2005
6
CMS Imaging Reporting
7
Hospital Compare CT Scans
Hospitalcompare.hhs.gov
8
Hospital Compare Follow Up Mammograms
Hospitalcompare.hhs.gov
9
Procedure Utilization Review
  • Prior approaches
  • Review of individual cases
  • Black box rules
  • Third party gatekeepers

10
ACC Survey of RBM/Prior Authorization Practice
11
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)

12
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
13
Rand/UCLA Rating Method
Adapted from Fitch K, et al. The RAND/UCLA
Appropriateness Method Users Manual, 2001, 4
14
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

15
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

16
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

17
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

18
Examples
  • Revascularization
  • PCI
  • Echo
  • ICD

19
Coronary Revascularization
20
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

21
STEMI
Patel, JACC 2009
22
ACS Algorithm
Patel, JACC 2009
23
Appropriate use criteria for revascularization
help measure quality
24
Appropriate Use of PCI
25
Percutaneous Coronary Intervention (PCI) Registry
26
Variation in Inappropriate Use of PCI
Chan JAMA 2011
27
Volume and Inappropriate PCI
R0.06
Rate of Inappropriate PCI ()
PCI Procedure Volume
Chan JAMA 2011
28
CATH-PCI Reports
29
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
30
ValidationAppropriate PCI
Chan, JACC 2011
31
ValidationUncertainAppropriateness PCI
Chan, JACC 2011
32
ValidationInappropriate PCI
Chan, JACC 2011
33
Appropriate Use of Implantable Defibrillators ICD
34
ICD Use in Primary Prevention
All-Khatib, JAMA 2011
35
Rates of Non-Evidence Based ICD Implantation
All-Khatib, JAMA 2011
36
Individual Reasons for Not Meeting Guidelines
All-Khatib, JAMA 2011
37
Appropriate Use of Stress Imaging
38
Inappropriate Stress Echo
Douglas, JACC 2008
39
Appropriateness of Stress Echo in Valve Disease
Douglas, JACC 2008
40
Appropriateness of Stress Imaging
Gibbons JACC 2008
41
Inappropriate Stress Indications
Gibbons,s JACC 2008
42
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
43
Appropriate Use of Echocardiography
44
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45
Inappropriate Echo Indications
Rahimi AJC 2011
46
Inappropriate Echocardiograms
Rahimi AJC 2011
47
Hospital and Provider TypeUniversity of Miami
Echo
Plt0.05
Willens JASE 2009
48
Inappropriate Echocardiograms
Ward, JACC Imaging 2008
49
Inappropriate Echo Results
Major includes wall motion abnormality, moderate
valve disease, pulmonary HTN, LVEF lt 40, RV
dysfunction
Ward, JACC Imaging 2008
50
Repeat Echocardiograms Less Appropriate by
Criteria
Ghatak, Echocardiography 2011
51
Appropriateness of Echocardiograms VA Palo Alto
52
Research Purpose
  • To determine if a statement in the
    echocardiography report can lead to more
    appropriate studies.

53
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

54
Incorporated Into Work Flow
  • Reader determines if follow-up statement should
    be added
  • Reporting system randomly includes or does not
    include the statement

55
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

56
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

57
Analysis
  • Primary first echocardiogram per patient
  • Secondary multiple echocardiograms per patient

58
Progress
  • Study Initiated 7/2012
  • 1032 reports randomized 5050
  • 989 unique patients
  • 849 negative recommendations
  • 183 positive recommendations

59
Follow Up Studies
60
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

61
Left Ventriculography
62
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63
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64
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)

65
Appropriateness Left Ventriculography
  • Use during coronary angiography
  • gt80 among Aetna patients despite recent
    echocardiogram
  • Does the rate vary across facilities?

Witteles, AHJ 2012
66
Variation in LVgram Use
67
LV Gram Appropriateness Intervention
  • 1) Have VA providers of left ventriculography
    (invasive cardiologists) rate appropriateness of
    different scenarios.

68
LV Gram Appropriateness Intervention
  • 2) Determine appropriateness using the VAs
    national catheterization laboratory reporting
    system

69
LV Gram Appropriateness Intervention
  • 3) Feedback performance to each VA laboratory.

70
Progress?
71
Appropriateness of Echo
Rahimi AJC 2011
72
Nuclear Medicine Use
Levin Health Affairs, 2010
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