Appropriateness of Cardiac Care

Appropriateness of Appropriateness of Cardiac CareCardiac Care

4/11/20124/11/2012

Paul Heidenreich, MD, MSPaul Heidenreich, MD, MS

Palo Alto VAPalo Alto VA

Relative RelationshipsRelative Relationships

Served on American College of Cardiology Served on American College of Cardiology (ACC) appropriateness rating panel for (ACC) appropriateness rating panel for echocardiographyechocardiography

Currently on writing committee for ACC Currently on writing committee for ACC ICD/CRT appropriateness criteriaICD/CRT appropriateness criteria

Past research grant from MedtronicPast research grant from Medtronic

OutlineOutline

Appropriateness as a measure of qualityAppropriateness as a measure of quality Examples of criteriaExamples of criteria

Echo, Stress TestingEcho, Stress Testing Is US care appropriate?Is US care appropriate?

Echo, ICD, PCIEcho, ICD, PCI Research in Progress: Two Interventions Research in Progress: Two Interventions

to improve appropriatenessto improve appropriateness

Why Appropriateness?Why Appropriateness?

Progressive

Increase in

Office Cardiac Imaging

Levin Health Affairs, 2010

Total

Office

OP Hospital

Need for Appropriateness: 15-fold Need for Appropriateness: 15-fold Variation in Coronary Variation in Coronary Stenting/AngioplastyStenting/Angioplasty

Dartmouth Atlas 2005

CMS Imaging CMS Imaging ReportingReporting

Hospital Compare: CT Hospital Compare: CT ScansScans

Hospitalcompare.hhs.gov

Hospital Compare: Hospital Compare: Follow Up MammogramsFollow Up Mammograms

Hospitalcompare.hhs.gov

Procedure Utilization Procedure Utilization ReviewReview

Prior approachesPrior approaches Review of individual casesReview of individual cases Black box rulesBlack box rules Third party gatekeepersThird party gatekeepers

ACC Survey of ACC Survey of RBM/Prior Authorization RBM/Prior Authorization

PracticePractice

Goals of Appropriateness Goals of Appropriateness MeasuresMeasures

- Create partnerships for rational/fair CV use of procedures Create partnerships for rational/fair CV use of procedures and related reimbursement (clinicians, health plans, and related reimbursement (clinicians, health plans, policymakers and payers)policymakers and payers)

- Educate clinicians on their practice habits Educate clinicians on their practice habits

- Stewardship of health care resourcesStewardship of health care resources

- Improve cost effectiveness of CV procedures (imaging, Improve cost effectiveness of CV procedures (imaging, stenting, devices)stenting, devices)

Understanding Quality in Procedure Understanding Quality in Procedure UtilizationUtilization

UnderuseUnderuse Failure to apply treatment in those Failure to apply treatment in those

likely to benefitlikely to benefit OveruseOveruse

Applying treatment to patients in whom Applying treatment to patients in whom risks risks > > benefitsbenefits

Appropriate Use

Criteria

Guidelines

Rand/UCLA Rating Rand/UCLA Rating MethodMethod

Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method User’s Manual, 2001, 4

Rating of IndicationsRating of Indications

7-9: Appropriate test for specific indication 7-9: Appropriate test for specific indication Test Test isis generally acceptable and generally acceptable and isis a reasonable a reasonable

approach for the indicationapproach for the indication

4-6: Uncertain or unclear if appropriate for specific 4-6: Uncertain or unclear if appropriate for specific indicationindication

Test Test maymay be generally acceptable and be generally acceptable and maymay be a be a reasonable approach for the indication reasonable approach for the indication

1-3: Inappropriate test for specific indication 1-3: Inappropriate test for specific indication Test is Test is notnot generally acceptable and is generally acceptable and is notnot a a

reasonable approach for the indicationreasonable approach for the indication

Uncertain and Uncertain and InappropriateInappropriate

Uncertain does NOT indicate that the procedure Uncertain does NOT indicate that the procedure should NOT be performed for that indication, but should NOT be performed for that indication, but rather more information/research is need to reach rather more information/research is need to reach a firm conclusiona firm conclusion

Uncertain does NOT indicate that the procedure Uncertain does NOT indicate that the procedure should not be reimbursed for that indicationshould not be reimbursed for that indication

Inappropriate rate goal should never be 0%; Inappropriate rate goal should never be 0%; emphasize reduction in patterns of inappropriateemphasize reduction in patterns of inappropriate

AUC and CoverageAUC and Coverage

AUC are not coverage criteria but clinical AUC are not coverage criteria but clinical benchmarking toolsbenchmarking tools

Coverage can be broader and AUC target Coverage can be broader and AUC target clinical nuancesclinical nuances

Registry implementation: potential source of Registry implementation: potential source of information to track usage of procedures after information to track usage of procedures after coverage approvalcoverage approval

AUC DevelopmentAUC DevelopmentCompletedCompleted Nuclear Imaging (SPECT)Nuclear Imaging (SPECT)

October 2005October 2005 Cardiac CT/CMR Cardiac CT/CMR

September 2006September 2006 Echocardiography (TTE, TEE)Echocardiography (TTE, TEE)

July 2007July 2007 Echocardiography (Stress)Echocardiography (Stress)

December 2007December 2007 Coronary RevascularizationCoronary Revascularization

December, 2008December, 2008 Revised Nuclear ImagingRevised Nuclear Imaging May 2009May 2009

Revised CTRevised CT October 2010October 2010 Revised EchocardiographyRevised Echocardiography November 2010November 2010 Revised Coronary RevascularizationRevised Coronary Revascularization January 2012January 2012

In ProgressIn Progress Multi-modality criteriaMulti-modality criteria

Heart failureHeart failureAcute chest painAcute chest pain

Ischemic Heart DiseaseIschemic Heart Disease Vascular Disease UltrasoundVascular Disease Ultrasound Diagnostic CatheterizationDiagnostic CatheterizationICD/CRTICD/CRT

Examples Examples

Revascularization Revascularization PCIPCI

EchoEcho ICDICD

Coronary Coronary RevascularizationRevascularization

Revascularization Revascularization CriteriaCriteria

~200 Clinical scenarios rated by 17 ~200 Clinical scenarios rated by 17 expertsexperts

Based upon the potential benefit to be Based upon the potential benefit to be gained from PCI. Patients’ stratified by…gained from PCI. Patients’ stratified by… Severity of coronary anatomySeverity of coronary anatomy

Magnitude of ischemiaMagnitude of ischemia

Intensity of medical therapyIntensity of medical therapy

Severity of symptomsSeverity of symptoms

STEMISTEMI

Patel, JACC 2009

ACS AlgorithmACS Algorithm

Patel, JACC 2009

Appropriate use criteria for Appropriate use criteria for revascularization help measure revascularization help measure quality… quality…

23

Appropriate Use Appropriate Use of PCIof PCI

Percutaneous Coronary Percutaneous Coronary Intervention (PCI) Intervention (PCI)

RegistryRegistry

Variation in Inappropriate Variation in Inappropriate Use of PCIUse of PCI

Chan JAMA 2011

Volume and Volume and Inappropriate PCIInappropriate PCI

Chan JAMA 2011PCI Procedure VolumeR

ate

of

Inap

pro

pri

ate

PC

I (%

)

R=0.06

CATH-PCI ReportsCATH-PCI Reports

… … and uncover opportunities for cost savings or and uncover opportunities for cost savings or better resource deploymentbetter resource deployment

29

449410

56589

20157

106589

0

100000

200000

300000

400000

500000

600000

700000

2010

Proc

edur

es in

Cat

hPCI

Reg

istry

Not Classifiable

Inappropriate

Uncertain

Appropriate

3.2% of PCI procedures considered inappropriate.

If dropped to

2.2%=44,000,000 USD

Source: Chan et al, internal ACC analysis

ValidatioValidation:n:

AppropriAppropriate ate PCIPCI

Chan, JACC 2011

Validation:Validation:UncertainUncertain

AppropriatenAppropriateness ess

PCIPCI

Chan, JACC 2011

Validation:Validation:InappropriInappropri

ate ate PCIPCI

Chan, JACC 2011

AppropriatAppropriate Use of e Use of

ImplantabImplantable le

DefibrillatDefibrillators ICDors ICD

ICD Use in Primary ICD Use in Primary PreventionPrevention

All-Khatib, JAMA 2011

Rates of Non-Evidence Rates of Non-Evidence Based ICD ImplantationBased ICD Implantation

All-Khatib, JAMA 2011

Individual Reasons for Individual Reasons for Not Meeting GuidelinesNot Meeting Guidelines

All-Khatib, JAMA 2011

Appropriate Use Appropriate Use of Stress Imagingof Stress Imaging

Inappropriate Stress Inappropriate Stress EchoEcho

Douglas, JACC 2008

Appropriateness of Appropriateness of Stress Echo in Valve Stress Echo in Valve

DiseaseDisease

Douglas, JACC 2008

Appropriateness of Appropriateness of Stress ImagingStress Imaging

Gibbons JACC 2008

Inappropriate Stress Inappropriate Stress IndicationsIndications

Gibbons,s JACC 2008

ACCF and United

Healthcare Pilot

INDICATION

% INAPPROPRIATE

INDICATIONS

% TOTAL STUDIES

Detection of CAD. Asymptomatic, low CHD risk 44.5% 6.0%

Asymptomatic, post-revascularization < 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 %

Appropriateness Classification (n=5,928)

Rates same between patients with RBM and without RBM review

Appropriate Use Appropriate Use of of

EchocardiographEchocardiographyy

Inappropriate Echo Inappropriate Echo IndicationsIndications

Rahimi AJC 2011

Inappropriate Inappropriate EchocardiogramsEchocardiograms

Rahimi AJC 2011

Hospital and Provider Hospital and Provider Type:Type:

University of Miami EchoUniversity of Miami Echo

Willens JASE 2009

P<0.05

Inappropriate Inappropriate EchocardiogramsEchocardiograms

Ward, JACC Imaging 2008

Inappropriate Echo Inappropriate Echo ResultsResults

Ward, JACC Imaging 2008Major includes wall motion abnormality, moderate

valve disease, pulmonary HTN, LVEF < 40%, RV dysfunction

Repeat Repeat Echocardiograms: Echocardiograms: Less Appropriate by Less Appropriate by

CriteriaCriteria

Ghatak, Echocardiography 2011

Appropriateness of Appropriateness of Echocardiograms: VA Echocardiograms: VA

Palo AltoPalo Alto

Research PurposeResearch Purpose

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

InterventionIntervention

statement in the echo report:statement in the echo report: PositivePositive

Recommended in 2 weeksRecommended in 2 weeks Recommended in 6 monthsRecommended in 6 months Recommended in 1 yearRecommended in 1 year

Negative Negative Not recommended for at least 1 yearNot recommended for at least 1 year Not recommended for at least 3 yearsNot recommended for at least 3 years

Incorporated Into Work Incorporated Into Work FlowFlow

Reader determines if follow-up statement Reader determines if follow-up statement should be addedshould be added

Reporting system randomly includes or Reporting system randomly includes or does not include the statementdoes not include the statement

OutcomeOutcome

Positive statement (follow up Positive statement (follow up recommended by time period X months):recommended by time period X months): Echo within X months -25% to + 50%Echo within X months -25% to + 50%

9 months to 18 months OK for 1 year f/u9 months to 18 months OK for 1 year f/u

Negative statement (follow up not Negative statement (follow up not recommend for at least X monthsrecommend for at least X months Follow-up Echo not done in X months Follow-up Echo not done in X months

Exclusion From Analysis Exclusion From Analysis (if N small)(if N small)

Echo performed for new indicationEcho performed for new indication Patient leaves the Palo Alto VA health Patient leaves the Palo Alto VA health

care system before follow-up periodcare system before follow-up period DeathDeath Changed health systemsChanged health systems

AnalysisAnalysis

Primary: first echocardiogram per patientPrimary: first echocardiogram per patient Secondary: multiple echocardiograms per Secondary: multiple echocardiograms per

patientpatient

ProgressProgress

Study Initiated 7/2012Study Initiated 7/2012 1032 reports randomized 50:501032 reports randomized 50:50

989 unique patients989 unique patients 849 negative recommendations849 negative recommendations 183 positive recommendations183 positive recommendations

Follow Up StudiesFollow Up Studies

Follow-Up Studies after a Follow-Up Studies after a Negative Negative

RecommendationRecommendation 41 echo requests examined 41 echo requests examined

9 clearly inappropriate9 clearly inappropriate Plan to enroll until we have 100 Plan to enroll until we have 100

inappropriate follow-up echocardiogramsinappropriate follow-up echocardiograms

Left Left VentriculographyVentriculography

Test is not “ordered”.Test is not “ordered”. Decision made by the invasive cardiologist Decision made by the invasive cardiologist

at the time of coronary angiography.at the time of coronary angiography. Adds contrast (small risk of worsening Adds contrast (small risk of worsening

renal function)renal function) Adds radiation (minimal risk of cancer)Adds radiation (minimal risk of cancer)

Use ofUse ofLeft VentriculographyLeft Ventriculography

Use during coronary angiographyUse during coronary angiography >80% among Aetna patients despite >80% among Aetna patients despite

recent echocardiogramrecent echocardiogram Does the rate vary across facilities?Does the rate vary across facilities?

Appropriateness Appropriateness Left VentriculographyLeft Ventriculography

Witteles, AHJ 2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Left

Ven

tric

ulo

grap

hy

Du

rin

g C

oro

nar

y A

ngi

ogr

aph

y

Individual VA Hospitals

Variation in LVgram UseVariation in LVgram Use

LV Gram LV Gram Appropriateness Appropriateness

InterventionIntervention 1) Have VA providers of left 1) Have VA providers of left

ventriculography (invasive cardiologists) ventriculography (invasive cardiologists) rate appropriateness of different rate appropriateness of different scenarios.scenarios.

LV Gram LV Gram Appropriateness Appropriateness

InterventionIntervention 2) Determine appropriateness using the 2) Determine appropriateness using the

VA’s national catheterization laboratory VA’s national catheterization laboratory reporting systemreporting system

LV Gram LV Gram Appropriateness Appropriateness

InterventionIntervention 3) Feedback performance to each VA 3) Feedback performance to each VA

laboratory.laboratory.

Progress?Progress?

Appropriateness of EchoAppropriateness of Echo

Rahimi AJC 2011

Nuclear Medicine UseNuclear Medicine Use

Levin Health Affairs, 2010