2. Disclosures for Manesh R. Patel, MD  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

3. Disclosures for Steven R. Bailey, MD  Nothing to disclose

4. “Every system is perfectly designed to get the results it gets” Dr. Paul Batalden Dartmouth College

5. Outline – Appropriate Use Criteria  Why do we have them or need them?  How are they developed?  How are they and how will they be used?  Conclusion

6. Do you have a Framework for thinking about all cardiovascular procedures that occur at your hospital? 6

7. High Quality Cardiovascular Procedures Right Patient Right Procedure Decision Appropriate Use Criteria Guidelines Patient Preferences Performance Measures Quality Metrics Public Reporting Right Procedure Execution Right Outcome Ongoing trials and evidence 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)

8. Outline – Appropriate Use Criteria  Why do we have them or need them?  How are they developed?  How are they and how will they be used?  Conclusion

9. Cardiovascular Disease and the Baby Boom  10,000 people become Medicare eligible every day  Cardiovascular Care accounts for 43 cents of every Medicare Dollar  Successful Health Care systems will have to focus on heart care 9 Spending & Revenues as a Share of GDP

10. http://www.dartmouthatlas.org/ Variation in Care PCI Rates per 1,000 Medicare Enrollees (2002-03)

11. Need for Appropriateness: 15-fold variation Dartmouth Atlas 2005

14. Outline – Appropriate Use Criteria  Why do we have them or need them?  How are they developed?  How are they and how will they be used?  Conclusion

15. Development of CPG’s, Performance Measures, and Appropriate Use Documents Antman, Circulation 2009:119:1180-1185.

16. Goals  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)

17. Expert Panel rates the indications in two rounds 1 st Round – No interaction 2 nd Round – Panel interaction Literature Review and Synthesis of the Evidence List of indications and definitions Appropriateness Score (7-9) Appropriate (4-6) Possibly Appropriate/Uncertain (1-3) Inappropriate Retrospective comparison with clinical recordsProspective clinical decision aids Validation Appropriateness Determination % Use that is Appropriate, Uncertain, InappropriateIncrease Appropriateness AUC Methodology adapted from RAND appropriateness Method (Modified Delphi Process) Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method User’s Manual, 2001, 4

18. 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

19. AUC Terminology  Based on published RAND/UCLA documents.  Appropriate does not mean mandatory  Uncertain* does not mean inappropriate or questionable and is reimbursable  Inappropriate does not mean fraud?deceit ? Goal is not 0%, however, a consistent inappropriate patterns should be reviewed by physician practices After 6 years of discussion, the published literature, 3 years working with ACR, no consensus nor compelling reason for change.

20. Suspected CAD: No Prior Noninvasive Stress Imaging

21. Suspected CAD: Prior Noninvasive Stress Testing

22. Patients With Known Obstructive CAD

23. Evaluation of Arrhythmias

24. Preoperative Coronary Evaluation: Patients With No Prior Noninvasive Stress Testing

25. Evaluation of Valvular Disease

26. Conclusions Diagnostic Catheterization AUC  Determine need for RHC / LHC and Coronary Angiography  Asymptomatic Patients should not go directly to cath lab  Patients with symptoms and high pre-test probability may go directly to diagnostic cath  PCI decision may require FFR  Pre-operative patients should rarely go directly to cath if stable

27. Outline – Appropriate Use Criteria  Why do we have them or need them?  How are they developed?  How are they and how will they be used?  Conclusion

28. Non-acute PCIs Chan PS et al. JAMA 2011;306:53-61

29. Outline – Appropriate Use Criteria  Why do we have them or need them?  How are they developed?  How are they and how will they be used?  Conclusion

30. AUC - “The Preface” 1. AUC blends evidence-base and clinical experience and is concordant with Clinical Practice Guidelines 2. We recognize that some ambiguity is intrinsic to clinical decision making and that AUC is not a substitute for sound clinical judgment nor patient preference 3. Where practice patterns of individuals, groups or hospitals routinely conflict with AUC ratings, further evaluation and education, with tracking and feedback, should be considered 4. AUC facilitates reimbursement for “appropriate” and “uncertain” indications

31. Profession

32. Call to Action?  To preserve our specialty’s autonomy the ACC needs to provide direction and leadership with GL’s, PM’s and AUC to achieve the “Triple Aim”  Improve the quality and safety of care  Improve the health of populations  Lower overall/unit cost

33. Conclusions  Cost of imaging in medicine will not be sustainable (Medicare 14 billion dollars)  Cardiovascular imaging - currently being controlled by third party groups (revenue benefit managers)  Diagnostic Cath and PCI are likely to follow shortly!!  ACC-ACR working on trying to get together for AC criteria  Clinical trials for common indications needed - more to come

34. Conclusions:  Appropriate Use Criteria - meant for clinicians, patients, and payers  Reasonable care  Evaluate pattern of care  CAD burden, Ischemia, High burden of symptoms - revascularization warranted  Functional PCI and Revascularization will be central to the care of cardiovascular patients

35. AUC Take Aways  We have a professional role and responsibility around appropriateness  The vast majority of PCIs are appropriate  The AUC are not performance measures  Document angina and stress test results  Know / participate in your NCDR data  Focus on 'practical workflow' and advocacy with ACC and payers

38. Q & A