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Multi-center Assessment of the Utilization of SPECT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: The ACCF and United Healthcare SPECT Pilot Study .

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Multi-center Assessment of the Utilization of SPECT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: The ACCF and United Healthcare SPECT Pilot Study

Robert C. Hendel, Manual Cerqueira, Kathleen Hewitt, Karen Caruth, Joseph Allen, Neil Jensen, Michael Wolk, Pamela S. Douglas, Ralph Brindis, American College of Cardiology Foundation, Washington, DC, UnitedHealthcare, Minneapolis, MN

Robert C. Hendel, MD, FACC

Midwest Heart Specialists

Winfield, IL

Chairman, ACCF/UHC SPECT-MPI Pilot Study

Late Breaking Clinical Trials

American College of Cardiology Scientific Sessions 2009

March 29, 2009


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Presenter Disclosure Information Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

Robert C. Hendel, MD

The following relationships exist related to this presentation:

Consulting PGx Health Modest

Astellas Pharma Modest

GE Healthcare Modest

Research support Astellas Modest

GE Healthcare Modest

Organizational ACC (Appropriate Use Criteria Task Force)


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BACKGROUND Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Growth and cost of CV imaging has placed renewed attention on proper/optimal test ordering

  • True nature of utilization unknown

    • Overuse/underuse/appropriate use

  • Development and publication of SPECT-MPI appropriate use criteria (AUC) in 2005

    • Subsequent AUC for echo, CT, CMR

    • SPECT MPI revision 2009

  • Criteria widely available and increasingly being adopted, but evaluation in community practice settings required


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GOALS OF STUDY Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Assess feasibility of tracking AUC

    • Point-of-service data collection

    • Computer derived indication assignment

  • Determine patterns of use for SPECT MPI in clinical practice

  • Evaluate the impact of referral source

  • Identify selected areas (indications) for quality improvement


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METHODS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Sites selected by ACC from potential locations provided by UHC

  • Data collection instrument and web-based entry system developed

  • Automated algorithm created

  • Audit of automated indication assignments

  • On-demand reports

  • Periodic overall and site-specific summaries provided


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DATA COLLECTION FORM Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Front page

    • Patient Demographics

    • History & Risk Factors,

    • Prior procedures & Tests

  • Back page

    • Current Study

    • Reference section

  • Designed to be completed in one minute or less


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METHODS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Sites of Pilot


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METHODS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Enrollment Periods

3/1/08

8/15/08

10/15/08

2/28/09

SITE 1

2

3

4

5

6

1 SITE

2

3

4

5

6

Period 1 Period 2 Period 3

On-demand

Report

Paper

Report


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RESULTS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Patient Characteristics (n = 6,351)


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RISK ASSESSMENT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Automated Calculation and Indication Assignment

SYMPTOMATIC PATIENTS

(Diamond & Forrester)

ASYMPTOMATIC PATIENTS

(Framingham; CHD Risk)


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APPROPRIATENESS CLASSIFICATION Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: (n = 6,351)


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APPROPRIATENESS CLASSIFICATION Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Elimination of Unclassified (n = 5,928)


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APPROPRIATENESS CLASSIFICATION Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Based on Site

Inappropriate

Range: 4-22%

n = 578 1200 1448 1448 322 932


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APPROPRIATENESS CATEGORY Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Based on Patient Factors

9.8%

19.3%

13.6%

15.5%

n = 3,046 2,882 3,468 2,460

p < 0.0001 p = 0.039


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MOST COMMON “INAPPROPRIATE” INDICATIONS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:


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APPROPRIATENESS CATEGORY Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Based on Referral

p < 0.0001

13.2%

19.5%

16.1%

9.9%

70.7%

70.7%

n = 4,792 n = 1,136


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APPROPRIATENESS CATEGORY Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Based on Referral

p < 0.0001

13.2%

20.1%

16.0%

10.1%

70.9%

69.8%

n = 4,881 n = 1,047


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FEEDBACK TO SITES Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:


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INAPPROPRIATE SPECT-MPI Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Temporal Changes Based on Site


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CONCLUSIONS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Data collection and analysis regarding appropriate use of SPECT imaging is feasible in busy community practice environment

    • Easy to use, point-of-ordering tool with web-based data entry

    • Automated determination of appropriateness

    • On-demand, benchmarked reports

  • Variable rates of test appropriateness

  • Consistent inappropriate indications

    • Asymptomatic, low risk patient are most frequent

  • Feedback/education may influence on practice habits

  • Less inappropriate testing from cardiologists than non-cardiologists


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IMPLICATIONS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Physicians and other health care professionals, working with medical societies, recognize the current healthcare environment

    • Active measures to optimize performance and cost-effectiveness

    • Preserve patient access to evaluation and treatment

  • The development and implementation of appropriate use criteria may offer an alternative to prior authorization/pre-certification approaches

    • Transparency

    • Expanded information regarding practice habits

    • Facilitation of on-going quality improvement

    • Movement toward point-of-order application

    • Potential for wide-scale utilization

  • Establishment of partnership between ACC, subspeciality societies, and health plans regarding responsible approach to medical imaging and continued emphasis on improving the quality of care


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ACKNOWLEDGMENTS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • American Society of Nuclear Cardiology (ASNC)

  • UnitedHealthcare

  • Leadership of ACC

    • Especially Douglas Weaver, Ralph Brindis, Michael Wolk, Pamela Douglas, Jack Lewin, and Janet Wright

  • Staff from ACC, NCDR, and DCRI

    • Notably Joseph Allen, Karen Caruth, Wenqin Pan, and Nichole Kallas


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LIMITATIONS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

  • Non-evaluable data

    • Missing information

    • Conflicting indications

  • Rolling recruitment with inconsistent time periods

  • Lack of validation of computer-assigned indications

    • Multiple indications

    • Audits reveal variance

  • Educational initiatives inconsistently applied

  • Non-adjudicated SPECT interpretations


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AUDIT OF COMPUTER-ASSIGNED INDICATIONS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: VERSUS INDEPENDENT PHYSICIAN REVIEW


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SPECT RESULTS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Based on Appropriateness Category

APPROPRIATE

UNCERTAIN

INAPPROPRIATE

p < 0.0003


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INDICATION AND SPECT FINDINGS Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Most Common “Inappropriate” Indications


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PROBABILITY OF CORONARY ARTERY DISEASE Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: BASED ON AGE, GENDER AND SYMPTOMS(Diamond & Forrester)

CALCULATED

n = 6,332

ESTIMATED

n = 5,567


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CORONARY HEART DISEASE RISK Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: BASED ON FRAMINGHAM CRITERIA

ESTIMATED

n = 5,649

CALCULATED

n = 6,082


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REASON FOR TEST Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: Based on Appropriateness Category


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Literature Review and Synthesis of the Evidence Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria:

List of indications and definitions

Appropriateness Score

(7-9) Appropriate

(4-6) Uncertain

(1-3) Inappropriate

ACC METHODOLOGY FOR DEVELOPMENT OF APPROPRIATE USE CRITERIA (Rand/Modified Delphi Method)

Writing Group

Outside Review of Indications and Additional Modification Prior to Rating

External Reviewers

Balanced panel comprised of different types of experts rates the indications in two rounds

1st Round – No interaction

Face-to-Face Meeting

2nd Round – Panel interaction

Appropriateness Determination

Technical Panel

Retrospective comparison with clinical records

Prospective clinical decision aids

Implementation Working Group

Validation

% Use that is Appropriate, Uncertain, Inappropriate

Increase Appropriateness

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


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