Appropriate use Criteria
Sharmila Dorbala, MD,FACCDirector of Nuclear CardiologyAssociate Professor Radiology
Thursday, 13 October 2016; Time: 14:20-14:40 Session: Fundamentals III: Safety and quality
Disclosures
Grants: • Astellas• American Heart Association• National Institutes of Health
Overview: Appropriate Use Criteria
• Why?• Methodology• Literature review• Tools
Institute of Medicine: Core Needs for Health Care
•Safe•Effective•Patient‐centered•Timely•Efficient•Equitable
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century
AUC: Why?
Increasing radiation burden from imaging
Einstein AE. J Am Coll Cardiol. 2012;59:553‐65.PMC3272627
A six fold increase in medical radiation A 2.5 fold increase in MPI volume
Rising health care costs related to imaging
Report to Congressional Requesters: Medicare Part B Imaging Services—Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices.Washington, DC: U.S.
Government Accountability Office; 2008
Methods to manage utilization of imaging
• Insurance providers: Prior authorization, radiology benefit managers, denial
• Medical societies: Appropriate use criteria• Radionuclide AUC 2005, was one of the first AUC documents in the series
• Centers for Medicare & Medicaid Services (CMS) requires incorporation of AUC into a clinical decision support system starting in 2018
Guidelines vs. Performance Measures vs. AUC
• Guidelines • Exhaustive review of literature• Virtually all‐inclusive• Best practice • “Should do, should not do”
Class I, Class III, Class IIa, IIb
• Performance measures• Selective• Largely guideline based• “Must do”• Tools for quality measurement
• Appropriate Use Criteria ‐ AUC • Selective indications• Largely guideline based• Clinical scenarios/frequency • “Reasonable to do”
Slide adapted from Ralph Brindis Current Status of Evidence Appraisal in Appropriateness Criteria Development
J Am Coll Cardiol. 2005;46(8):1606‐1613
ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging
AUC: Definition
• “An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.”
J Am Coll Cardiol. 2005;46(8):1606‐1613
AUC methodology & terminology
Median score
RNI AUC2005 (Indications=52)
RNI AUC2009 (Indications = 67)
7‐9 Appropriate (27) Appropriate(33)
4‐6 Uncertain(12)
May be appropriate(9)
1‐3 Inappropriate(13)
Rarely appropriate(25)
Dorbala et al. J Nuc Med. 2015;63:380-406
Appropriate use criteria: PET and SPECT equivalent
Multimodality AUC for Detection of CAD/Risk assessment
I. Detection of CAD/Risk assessmentII. Prior testing or procedureIII. Preoperative evaluation for non cardiac surgeryIV. Determine exercise level prior to initiation of exercise prescription or
cardiac rehabilitation
Wolk et al. J Am Coll Cardiol. 2014;63:380-406
Frequency of appropriate indications for SPECT MPI: Variable
80
6471
6066
75
63
82 84
62
52
63
73
8477
88
0
10
20
30
40
50
60
70
80
90
100
Appropriate Uncertain Inappropriate
Data From: Hendel RC. J Nucl Cardiol. 2015;22:16‐21
Appropriate MPI: Abnormal scans and events highest
55
33
40 40
58
126
1014
47 47
21 2115
74
0
9
32
11
27
18
7
33
2 15 3 3
0
10
20
30
40
50
60
70
Appropriate Uncertain Inappropriate
Data From: Hendel RC. J Nucl Cardiol. 2015;22:16‐21
Abnormal MPI Events
Doukky et al. Circulation. 2013;128:1634‐43
Rates of coronary angiography and revascularization: Ischemia driven & high regardless of appropriateness
Appropriate/Uncertain N=823, 54.5%Inappropriate, N=688, 45.5%
Doukky et al. Circulation. 2013;128:1634‐43
Rates of events low with inappropriate MPI irrespective of scan results
Results of AUC: Optimize appropriateness of testing
Desai et al. JAMA. 2015;314:2045-53
Top 5 most frequent inappropriate indications: A multicenter study
Hendel RC et al. J Am Coll Cardiol. 2010;55:156‐62
ABIM Choosing Wisely
Dorbala et al. J Nuc Med. 2010;55:156‐62
AUC: Unresolved questions
•Time of order•Time of test•Whose responsibility
•Referring MD• Imaging MD•Patient
•Reimbursement•Which societal AUC?
AUC decision support tool at time of order: Reduced inappropriate tests, changed medical Rx
Lin et al. J Am Coll Cardiol. 2013;62:308‐16
100 physicians, 472 patients over 8 months
JAMA Cardiol. 2016;1(2):207-210.
ACCF No./Total (%)Inappropriate
ACR No/Total (%)Usually not appropriate
Ischemia SDS > 3 1/39 (2.6) 14/80 (17.5%)
Abnormal MPI 3/41 (7.3) 29/82 (35.4%)
Discordance Between AUC for Nuclear MPI From Different Specialty Societies: A Potential Concern for Health Policy
AUC: Conclusions
• Nuclear cardiology technology has advanced tremendously• AUC developed to
• Use medical resources efficiently• Improve quality of medical care• Evaluate under or over utilization
• Online apps are available and tools at point of order are evolving• Unresolved issues
• AUC may soon be linked to payment for services• Agreement between AUC from different societies
AUC: Take home points
• Do not perform • Routine annual testing after coronary artery revascularization• Stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high‐risk markers are present
• Cardiac imaging in patients who are low risk• Radionuclide imaging as a part of routine follow‐up of asymptomatic patients
• Preoperative assessment in patients scheduled to undergo low or intermediate risk non cardiac surgery
• Use methods to reduce radiation exposure in cardiac imaging whenever feasible, including not performing the tests when the benefits will likely be limited
Funding Sources
Amyloidosis FoundationAmerican Society of Nuclear Cardiology
Tangley Lloyd FoundationBurt Glazov FoundationDeMoulas Foundation
National Institutes of HealthAmerican Heart Association
BWH Cardiovascular imaging
Marcelo Di Carli, MDRon Blankstein, MDHicham Skali, MDViviany Taqueti, MD
FacultyFellowsStaff
Thank you
SAVE THE DATE 7-9 May 2017, Vienna AUSTRIA
Call for abstracts & clinical cases15 Sept – 21 Nov 2016
Early registration fee deadline 27 February 2017
Differences between Radionuclide AUC 2009 and Multimodality AUC 2013
Hendel RC. J Nucl Cardiol. 2015;22:16‐21