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