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CP1279194-16

Rates of Imaging Stress Testing. # 1000 enrollees. Wennberg et al: The Dartmouth Atlas of Cardiovascular Health Care, 1999. CP1279194-16. Indications for Cardiac CT. Asymptomatic Patients. Family history of CAD High triglyceride levels, smoking, diabetes, etc.

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CP1279194-16

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  1. Rates of Imaging Stress Testing # 1000 enrollees Wennberg et al: The Dartmouth Atlas of Cardiovascular Health Care, 1999 CP1279194-16

  2. Indications for Cardiac CT Asymptomatic Patients • Family history of CAD • High triglyceride levels, smoking, diabetes, etc. • ECG abnormalities on a routine health check-up • Equivocal abnormalities on a routine stress test • Moderate to severe hypertension • Prior to non-coronary surgery in the adult population • www.ctcardiac.com CP1034655-44

  3. Cardiac CT Media Coverage “The images it creates are so detailed that cardiac specialists can…actually see the particles of plaque.” “It also can help decide whether blood-pressure and cholesterol-lowering drugs are effective or even necessary.” Appleton, WI, Post-Crescent November 29, 2005 CP1227206-4

  4. Screening for CAD-CT Calc ACC/AHA Low-Risk Not rec(Class III) Inter-Risk Maybe(Class IIb) High-Risk Not rec(Class III) Circ 114:1761, 2006; JACC 49: 378, 2007 CP1166804-6

  5. CTAAHA Recommendations • Class IIa • CAD in symptomatic pt (LOE B) • Coronary anomalies (LOE C) • Class IIb • Bypass grafts (LOE C) • Class III • Asymptomatic pt (LOE C) • Follow-up of stents (LOEC) Circ 114:1761, 2006 CP1283309-5

  6. Cancer Risk CTA Women Lifetimecancer(%) Men Age (yr) JAMA 298:317, 2007 CP1279194-14

  7. Health care crisis • Attention on imaging • Quality • Efficiency CP1279194-10

  8. ST Elevation MIEligible Patients - NO Reperfusion Therapy

  9. Acute StrokeEligible Patients - NO Thrombolytic Therapy % Arch Neur 61:346, 2004, Neurology 56:1015, 2001, Stroke 32:1061, 2001, Neurology 67:88, 2006 CP1243922-4

  10. Quality of Care – 2004 Minnesota Optimal care (%) CAD Diabetes Minnesota Qcare CP1247245-1

  11. COURAGEOptimal Medical Therapy Prevalence at 5 yr (%) NEJM 356:1503, 2007 CP1283309-4

  12. Failure RateNuclear Cardiology Core Lab % N=489 N=895

  13. Health care crisis • Attention on imaging • Quality • Efficiency CP1279194-11

  14. Health Expenditures – 2004% of Gross Domestic Product

  15. Self-Reported Disease Prevalence UK U.S. % Diabetes  BP MI Stroke JAMA 295:2034, 2006 CP1247245-5

  16. 10.0 UCLA Medical Center 9.2 9.0 8.0 Cedars-Sinai Medical Center 7.0 NYU Medical Center 6.7 7.0 6.0 5.0 NY Presbyterian Hospital 4.5 Stanford University Hospital 4.3 4.0 Mount Sinai Hospital 2.8 UCSF Medical Center 2.6 3.0 2.0 1.0 ICU Days Last 6 Months of Life Dartmouth Health Care Atlas

  17. Stress SPECT AppropriatenessMayo Nuclear Cardiology Unclassified 11% Appropriate 64% Uncertain 11% Inappropriate 14% CP1278686-14

  18. Inappropriate Stress Imaging Studies Mayo SPECT Echo Category (N) (N) % of inapp Asymp Low-risk pt 20 25 48 PreopIntermediate-risk surg 4 12 17 Good ex capacity Sx Low pre test 5 7 13 Interp ECG, able to exercise Preop Low-risk surg 2 7 10 These 4 categories 88 CP1279194-12

  19. Total Medicare Expense per Capita2003 $7,000 to $11,352 (64) $6,000 to <$6,500 (56) $4,272 to <$5,500 (70) $6,500 to <$7,000 (53) $5,500 to <$6,000 (64) Not populated CP1283309-3

  20. Total Medicare Reimbursements/Enrollee – 2003Hospital Referral Regions Philadelphia Johnstown Scranton Pittsburgh Wilkes-Barre Erie Altoona Allentown Reading Harrisburg Lancaster Danville York Sayre CP1283309-2

  21. Lancaster 10.6 Allentown 10.8 Harrisburg 11.2 Wilkes-Barre 10.9 Johnstown 16.2 Altoona 14.1 Pittsburgh 11.7 Reading 11.7 Sayre 9.7 Scranton 9.9 Philadelphia 9.8 York 8.8 Erie 8.8 Danville 5.4 Percutaneous Coronary Interventions – 2003Hospital Referral Regions PCI/1,000 enrollees CP1283309-1

  22. Cleveland 12.4 Baltimore 12.4 Durham 9.7 Rochester, MN 9.6 Boston 8.6 Percutaneous Coronary Interventions – 2003Hospital Referral Regions PCI/1,000 enrollees CP1283309-7v2

  23. Closing Thoughts • We must begin to regulate ourselves by eliminating inappropriate tests, reducing procedures and care that have marginal benefit, improving quality CP1279194-6

  24. Closing Thoughts • Required major fix of the health care system will be painful – the longer we wait, the more painful it will be CP1279194-6

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