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 Served on American College of Cardiology (ACC) appropriateness rating panel for echocardiography Currently on writing committee for ACC ICD/CRT appropriateness criteria Currently on writing committee for ACC ICD/CRT appropriateness criteria Past research grant from Medtronic Past research grant from Medtronic

3. Outline Appropriateness as a measure of quality Appropriateness as a measure of quality Examples of criteria Examples of criteria Echo, Stress Testing Echo, Stress Testing Is US care appropriate? Is US care appropriate? Echo, ICD, PCI Echo, ICD, PCI Research in Progress: Two Interventions to improve appropriateness Research in Progress: Two Interventions to improve appropriateness

4. Why Appropriateness? Progressive Increase in Office Cardiac Imaging Levin Health Affairs, 2010 Total Office OP Hospital

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 Prior approaches Review of individual cases Review of individual cases Black box rules Black box rules Third party gatekeepers 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 Underuse Failure to apply treatment in those likely to benefit Failure to apply treatment in those likely to benefit Overuse Overuse Applying treatment to patients in whom risks > benefits Applying treatment to patients in whom risks > benefits Appropriate Use Criteria Guidelines

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 7-9: Appropriate test for specific indication Test is generally acceptable and is a reasonable approach for the indication Test is generally acceptable and is a reasonable approach for the indication 4-6: Uncertain or unclear if appropriate for specific 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 Test may be generally acceptable and may be a reasonable approach for the indication 1-3: Inappropriate test for specific indication 1-3: Inappropriate test for specific indication Test is not generally acceptable and is not a reasonable approach for the 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 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 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 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 AUC are not coverage criteria but clinical benchmarking tools Coverage can be broader and AUC target clinical nuances Coverage can be broader and AUC target clinical nuances Registry implementation: potential source of information to track usage of procedures after coverage approval Registry implementation: potential source of information to track usage of procedures after coverage approval

17. AUC Development Completed Nuclear Imaging (SPECT) Nuclear Imaging (SPECT) October 2005 Cardiac CT/CMR Cardiac CT/CMR September 2006 Echocardiography (TTE, TEE) Echocardiography (TTE, TEE) July 2007 Echocardiography (Stress) Echocardiography (Stress) December 2007 Coronary Revascularization Coronary Revascularization December, 2008 Revised Nuclear Imaging Revised Nuclear Imaging May 2009 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 Revascularization PCI PCI Echo Echo ICD ICD

19. Coronary Revascularization

20. Revascularization Criteria ~200 Clinical scenarios rated by 17 experts ~200 Clinical scenarios rated by 17 experts Based upon the potential benefit to be gained from PCI. Patients’ stratified by… Based upon the potential benefit to be gained from PCI. Patients’ stratified by… Severity of coronary anatomy Severity of coronary anatomy Magnitude of ischemia Magnitude of ischemia Intensity of medical therapy Intensity of medical therapy Severity of symptoms Severity of symptoms

21. STEMI Patel, JACC 2009

22. ACS Algorithm Patel, JACC 2009

23. Appropriate use criteria for revascularization help measure quality… 23

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 Chan JAMA 2011 PCI Procedure Volume Rate of Inappropriate PCI (%) R=0.06

28. CATH-PCI Reports

29. … and uncover opportunities for cost savings or better resource deployment 29 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: Uncertain Appropriateness 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 INDICATION % INAPPROPRIATE INDICATIONS % TOTAL STUDIES Detection of CAD. Asymptomatic, low CHD risk44.5%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 surgery3.8%0.5 % TOTAL92.1%12.4 % 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 Willens JASE 2009 P<0.05

48. Inappropriate Echocardiograms Ward, JACC Imaging 2008

49. Inappropriate Echo Results Ward, JACC Imaging 2008 Major includes wall motion abnormality, moderate valve disease, pulmonary HTN, LVEF < 40%, RV dysfunction

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

53. Intervention statement in the echo report: statement in the echo report: Positive Positive Recommended in 2 weeks Recommended in 2 weeks Recommended in 6 months Recommended in 6 months Recommended in 1 year Recommended in 1 year Negative Negative Not recommended for at least 1 year Not recommended for at least 1 year Not recommended for at least 3 years Not recommended for at least 3 years

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

55. Outcome Positive statement (follow up recommended by time period X months): Positive statement (follow up 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/u 9 months to 18 months OK for 1 year f/u Negative statement (follow up not recommend for at least X months Negative statement (follow up not recommend for at least X months Follow-up Echo not done in X months Follow-up Echo not done in X months

56. Exclusion From Analysis (if N small) Echo performed for new indication Echo performed for new indication Patient leaves the Palo Alto VA health care system before follow-up period Patient leaves the Palo Alto VA health care system before follow-up period Death Death Changed health systems Changed health systems

57. Analysis Primary: first echocardiogram per patient Primary: first echocardiogram per patient Secondary: multiple echocardiograms per patient Secondary: multiple echocardiograms per patient

58. Progress Study Initiated 7/2012 Study Initiated 7/2012 1032 reports randomized 50:50 1032 reports randomized 50:50 989 unique patients 989 unique patients 849 negative recommendations 849 negative recommendations 183 positive recommendations 183 positive recommendations

59. Follow Up Studies

60. Follow-Up Studies after a Negative Recommendation 41 echo requests examined 41 echo requests examined 9 clearly inappropriate 9 clearly inappropriate Plan to enroll until we have 100 inappropriate follow-up echocardiograms Plan to enroll until we have 100 inappropriate follow-up echocardiograms

61. Left Ventriculography

64. Test is not “ordered”. Test is not “ordered”. Decision made by the invasive cardiologist at the time of coronary angiography. Decision made by the invasive cardiologist at the time of coronary angiography. Adds contrast (small risk of worsening renal function) Adds contrast (small risk of worsening renal function) Adds radiation (minimal risk of cancer) Adds radiation (minimal risk of cancer) Use of Left Ventriculography

65. Use during coronary angiography Use during coronary angiography >80% among Aetna patients despite recent echocardiogram >80% among Aetna patients despite recent echocardiogram Does the rate vary across facilities? Does the rate vary across facilities? Appropriateness Left Ventriculography 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. 1) Have VA providers of left ventriculography (invasive cardiologists) rate appropriateness of different scenarios.

68. LV Gram Appropriateness Intervention 2) Determine appropriateness using the VA’s national catheterization laboratory reporting system 2) Determine appropriateness using the VA’s national catheterization laboratory reporting system

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

70. Progress?

71. Appropriateness of Echo Rahimi AJC 2011

72. Nuclear Medicine Use Levin Health Affairs, 2010