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Appropriateness of Cardiac Care. 4/11/2012 Paul Heidenreich, MD, MS Palo Alto VA. Relative Relationships. Served on American College of Cardiology (ACC) appropriateness rating panel for echocardiography Currently on writing committee for ACC ICD/CRT appropriateness criteria

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Appropriateness of Cardiac Care

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Appropriateness of cardiac care

Appropriateness of Cardiac Care


Paul Heidenreich, MD, MS

Palo Alto VA

Relative relationships

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



  • 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

Why appropriateness

Why Appropriateness?

Progressive Increase in

Office Cardiac Imaging



OP Hospital

Levin Health Affairs, 2010

Need for appropriateness 15 fold variation in coronary stenting angioplasty

Need for Appropriateness: 15-fold Variation in Coronary Stenting/Angioplasty

Dartmouth Atlas 2005

Cms imaging reporting

CMS Imaging Reporting

Hospital compare ct scans

Hospital Compare: CT Scans

Hospital compare follow up mammograms

Hospital Compare: Follow Up Mammograms

Procedure utilization review

Procedure Utilization Review

  • Prior approaches

    • Review of individual cases

    • Black box rules

    • Third party gatekeepers

Acc survey of rbm prior authorization practice

ACC Survey of RBM/Prior Authorization Practice

Goals of appropriateness measures

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)

Understanding quality in procedure utilization

Understanding Quality in Procedure Utilization

  • Underuse

    • Failure to apply treatment in those likely to benefit

  • Overuse

    • Applying treatment to patients in whom risks > benefits


Appropriate Use Criteria

Rand ucla rating method

Rand/UCLA Rating Method

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

Rating of indications

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

Uncertain and inappropriate

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

Auc and coverage

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

Auc development


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


AUC Development



  • Revascularization

    • PCI

  • Echo

  • ICD

Coronary revascularization

Coronary Revascularization

Revascularization criteria

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



Patel, JACC 2009

Acs algorithm

ACS Algorithm

Patel, JACC 2009

Appropriate use criteria for revascularization help measure quality

Appropriate use criteria for revascularization help measure quality…

Appropriate use of pci

Appropriate Use of PCI

Percutaneous coronary intervention pci registry

Percutaneous Coronary Intervention (PCI) Registry

Variation in inappropriate use of pci

Variation in Inappropriate Use of PCI

Chan JAMA 2011

Volume and inappropriate pci

Volume and Inappropriate PCI


Rate of Inappropriate PCI (%)

PCI Procedure Volume

Chan JAMA 2011

Cath pci reports

CATH-PCI Reports

And uncover opportunities for cost savings or better resource deployment

… and uncover opportunities for cost savings or better resource deployment

3.2% of PCI procedures considered inappropriate.

If dropped to


44,000,000 USD

Source: Chan et al, internal ACC analysis

Validation appropriate pci

Validation:Appropriate PCI

Chan, JACC 2011

Validation uncertain appropriateness pci

Validation:UncertainAppropriateness PCI

Chan, JACC 2011

Validation inappropriate pci

Validation:Inappropriate PCI

Chan, JACC 2011

Appropriate use of implantable defibrillators icd

Appropriate Use of Implantable Defibrillators ICD

Icd use in primary prevention

ICD Use in Primary Prevention

All-Khatib, JAMA 2011

Rates of non evidence based icd implantation

Rates of Non-Evidence Based ICD Implantation

All-Khatib, JAMA 2011

Individual reasons for not meeting guidelines

Individual Reasons for Not Meeting Guidelines

All-Khatib, JAMA 2011

Appropriate use of stress imaging

Appropriate Use of Stress Imaging

Inappropriate stress echo

Inappropriate Stress Echo

Douglas, JACC 2008

Appropriateness of stress echo in valve disease

Appropriateness of Stress Echo in Valve Disease

Douglas, JACC 2008

Appropriateness of stress imaging

Appropriateness of Stress Imaging

Gibbons JACC 2008

Inappropriate stress indications

Inappropriate Stress Indications

Gibbons,s JACC 2008

Appropriateness of cardiac care

ACCF and United Healthcare Pilot

Appropriateness Classification (n=5,928)

Rates same between patients with RBM and without RBM review

Appropriate use of echocardiography

Appropriate Use of Echocardiography

Inappropriate echo indications

Inappropriate Echo Indications

Rahimi AJC 2011

Inappropriate echocardiograms

Inappropriate Echocardiograms

Rahimi AJC 2011

Hospital and provider type university of miami echo

Hospital and Provider Type:University of Miami Echo


Willens JASE 2009

Inappropriate echocardiograms1

Inappropriate Echocardiograms

Ward, JACC Imaging 2008

Inappropriate echo results

Inappropriate Echo Results

Major includes wall motion abnormality, moderate valve disease,

pulmonary HTN, LVEF < 40%, RV dysfunction

Ward, JACC Imaging 2008

Repeat echocardiograms less appropriate by criteria

Repeat Echocardiograms: Less Appropriate by Criteria

Ghatak, Echocardiography 2011

Appropriateness of echocardiograms va palo alto

Appropriateness of Echocardiograms: VA Palo Alto

Research purpose

Research Purpose

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



  • statement in the echo report:

    • Positive

      • Recommended in 2 weeks

      • Recommended in 6 months

      • Recommended in 1 year

    • Negative

      • Not recommended for at least 1 year

      • Not recommended for at least 3 years

Incorporated into work flow

Incorporated Into Work Flow

Reader determines if follow-up statement should be added

Reporting system randomly includes or does not include the statement



  • Positive statement (follow up recommended by time period X months):

    • Echo within X months -25% to + 50%

      • 9 months to 18 months OK for 1 year f/u

  • Negative statement (follow up not recommend for at least X months

    • Follow-up Echo not done in X months

Exclusion from analysis if n small

Exclusion From Analysis (if N small)

  • Echo performed for new indication

  • Patient leaves the Palo Alto VA health care system before follow-up period

    • Death

    • Changed health systems



Primary: first echocardiogram per patient

Secondary: multiple echocardiograms per patient



  • Study Initiated 7/2012

  • 1032 reports randomized 50:50

    • 989 unique patients

  • 849 negative recommendations

  • 183 positive recommendations

Follow up studies

Follow Up Studies

Follow up studies after a negative recommendation

Follow-Up Studies after a Negative Recommendation

  • 41 echo requests examined

    • 9 clearly inappropriate

  • Plan to enroll until we have 100 inappropriate follow-up echocardiograms

Left ventriculography

Left Ventriculography

Appropriateness of cardiac care

Use ofLeft Ventriculography

Test is not “ordered”.

Decision made by the invasive cardiologist at the time of coronary angiography.

Adds contrast (small risk of worsening renal function)

Adds radiation (minimal risk of cancer)

Appropriateness of cardiac care

Appropriateness Left Ventriculography

Use during coronary angiography

>80% among Aetna patients despite recent echocardiogram

Does the rate vary across facilities?

Witteles, AHJ 2012

Variation in lvgram use

Variation in LVgram Use

Lv gram appropriateness intervention

LV Gram Appropriateness Intervention

1) Have VA providers of left ventriculography (invasive cardiologists) rate appropriateness of different scenarios.

Lv gram appropriateness intervention1

LV Gram Appropriateness Intervention

2) Determine appropriateness using the VA’s national catheterization laboratory reporting system

Lv gram appropriateness intervention2

LV Gram Appropriateness Intervention

3) Feedback performance to each VA laboratory.



Appropriateness of echo

Appropriateness of Echo

Rahimi AJC 2011

Nuclear medicine use

Nuclear Medicine Use

Levin Health Affairs, 2010

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