Appropriateness of cardiac care
This presentation is the property of its rightful owner.
Sponsored Links
1 / 72

Appropriateness of Cardiac Care PowerPoint PPT Presentation


  • 88 Views
  • Uploaded on
  • Presentation posted in: General

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

Download Presentation

Appropriateness of Cardiac Care

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Appropriateness of cardiac care

Appropriateness of Cardiac Care

4/11/2012

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


Outline

Outline

  • 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

Total

Office

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

Hospitalcompare.hhs.gov


Hospital compare follow up mammograms

Hospital Compare: Follow Up Mammograms

Hospitalcompare.hhs.gov


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

Guidelines

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

Completed

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

ICD/CRT

AUC Development


Examples

Examples

  • 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


Stemi

STEMI

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

R=0.06

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

2.2%=

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

P<0.05

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.


Intervention

Intervention

  • 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


Outcome

Outcome

  • 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


Analysis

Analysis

Primary: first echocardiogram per patient

Secondary: multiple echocardiograms per patient


Progress

Progress

  • 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.


Progress1

Progress?


Appropriateness of echo

Appropriateness of Echo

Rahimi AJC 2011


Nuclear medicine use

Nuclear Medicine Use

Levin Health Affairs, 2010


  • Login