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

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

3. CP1227206-4 Cardiac CT Media Coverage 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.” “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 Appleton, WI, Post-Crescent November 29, 2005

4. CP1166804-6 Screening for CAD-CT Calc ACC/AHA Screening for CAD-CT Calc ACC/AHA Low-Risk Not rec(Class III) Inter-Risk Maybe(Class IIb) High-Risk Not rec(Class III) 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

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

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

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

8. ST Elevation MI Eligible Patients - NO Reperfusion Therapy

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

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

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

12. Failure Rate Nuclear Cardiology Core Lab % N=895 N=489

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

14. Health Expenditures – 2004 % of Gross Domestic Product

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

16. Dartmouth Health Care Atlas ICU Days Last 6 Months of Life

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

18. SPECTEcho Category(N)(N) % of inapp Asymp Low-risk pt202548 Preop Intermediate-risk surg 41217 Good ex capacity Sx Low pre test 5 713 Interp ECG, able to exercise Preop Low-risk surg 2 710 These 4 categories88 SPECTEcho Category(N)(N) % of inapp Asymp Low-risk pt202548 Preop Intermediate-risk surg 41217 Good ex capacity Sx Low pre test 5 713 Interp ECG, able to exercise Preop Low-risk surg 2 710 These 4 categories88 Mayo CP1279194-12 Inappropriate Stress Imaging Studies

19. CP1283309-3 Total Medicare Expense per Capita 2003 $7,000 to $11,352(64) $6,500 to <$7,000(53) $6,000 to <$6,500(56) $5,500 to <$6,000(64) $4,272 to <$5,500(70) Not populated

20. CP1283309-2 Total Medicare Reimbursements/Enrollee – 2003 Hospital Referral Regions JohnstownScrantonJohnstownScranton ReadingHarrisburgReadingHarrisburg LancasterLancaster YorkYork SayreSayre PhiladelphiaPhiladelphia AllentownAllentown DanvilleDanville ErieAltoonaErieAltoona PittsburghWilkes-BarrePittsburghWilkes-Barre

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

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

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

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