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 > benefits Guidelines Appropriate Use Criteria

13. Rand/UCLA Rating Method Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method User’s 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. 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 AUC Development

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 R=0.06 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. Validation:Appropriate PCI Chan, JACC 2011

31. Validation:UncertainAppropriateness PCI Chan, JACC 2011

32. Validation:Inappropriate 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 (n=5,928) Rates same between patients with RBM and without RBM review

43. Appropriate Use of Echocardiography

45. Inappropriate Echo Indications Rahimi AJC 2011

46. Inappropriate Echocardiograms Rahimi AJC 2011

47. Hospital and Provider Type:University of Miami Echo P<0.05 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 < 40%, RV dysfunction Ward, JACC Imaging 2008

50. Repeat Echocardiograms: Less Appropriate by Criteria Ghatak, Echocardiography 2011