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Multi-center Assessment of the Utilization of SPECT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: The ACCF and United Healthcare.

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Presentation on theme: "Multi-center Assessment of the Utilization of SPECT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: The ACCF and United Healthcare."— Presentation transcript:

1 Multi-center Assessment of the Utilization of SPECT Myocardial Perfusion Imaging Using the ACCF Appropriateness Criteria: The ACCF and United Healthcare SPECT Pilot Study Robert C. Hendel, Manual Cerqueira, Kathleen Hewitt, Karen Caruth, Joseph Allen, Neil Jensen, Michael Wolk, Pamela S. Douglas, Ralph Brindis, American College of Cardiology Foundation, Washington, DC, UnitedHealthcare, Minneapolis, MN Robert C. Hendel, MD, FACC Midwest Heart Specialists Winfield, IL Chairman, ACCF/UHC SPECT-MPI Pilot Study Late Breaking Clinical Trials American College of Cardiology Scientific Sessions 2009 March 29, 2009

2 Presenter Disclosure Information Robert C. Hendel, MD The following relationships exist related to this presentation: ConsultingPGx HealthModest Astellas PharmaModest GE HealthcareModest Research supportAstellasModest GE HealthcareModest OrganizationalACC (Appropriate Use Criteria Task Force)

3 BACKGROUND Growth and cost of CV imaging has placed renewed attention on proper/optimal test ordering True nature of utilization unknown –Overuse/underuse/appropriate use Development and publication of SPECT-MPI appropriate use criteria (AUC) in 2005 –Subsequent AUC for echo, CT, CMR –SPECT MPI revision 2009 Criteria widely available and increasingly being adopted, but evaluation in community practice settings required

4 GOALS OF STUDY Assess feasibility of tracking AUC –Point-of-service data collection –Computer derived indication assignment Determine patterns of use for SPECT MPI in clinical practice Evaluate the impact of referral source Identify selected areas (indications) for quality improvement

5 METHODS Sites selected by ACC from potential locations provided by UHC Data collection instrument and web-based entry system developed Automated algorithm created Audit of automated indication assignments On-demand reports Periodic overall and site-specific summaries provided

6 DATA COLLECTION FORM Front page –Patient Demographics –History & Risk Factors, –Prior procedures & Tests Back page –Current Study –Reference section Designed to be completed in one minute or less

7

8 METHODS Sites of Pilot StateLocale# MDs # patients enrolled Site 1FLUrban17635 Site 2FLUrban71293 Site 3WIRural151597 Site 4FLUrban201570 Site 5ORSuburban17328 Site 6AZSuburban9938

9 METHODS Enrollment Periods 3/1/088/15/082/28/0910/15/08 Period 1 Period 2 Period 3 On-demand Report Paper Report SITE 1 2 3 4 5 6 1 SITE 2 3 4 5 6

10 RESULTS Patient Characteristics (n = 6,351) Age, years 65.7±11.8 Gender, male3,72958.7% Diabetes1,44622.3% Smoker74311.7% Hypertension4,85676.7% Hyperlipidemia4,61672.9% Prior PCI1,80636.1% Prior CABG94519.7% Asymptomatic2,41438.0%

11 RISK ASSESSMENT Automated Calculation and Indication Assignment SYMPTOMATIC PATIENTS (Diamond & Forrester) ASYMPTOMATIC PATIENTS (Framingham; CHD Risk)

12 APPROPRIATENESS CLASSIFICATION (n = 6,351)

13 APPROPRIATENESS CLASSIFICATION Elimination of Unclassified (n = 5,928)

14 APPROPRIATENESS CLASSIFICATION Based on Site n = 578 1200 1448 1448 322 932 Inappropriate Range: 4-22%

15 APPROPRIATENESS CATEGORY Based on Patient Factors p < 0.0001 p = 0.039 n = 3,046 2,882 3,468 2,460 9.8%19.3%13.6%15.5%

16 MOST COMMON INAPPROPRIATE INDICATIONS INDICATION % INAPPRO INDICATIONS % TOTAL STUDIES Detection of CAD Asymptomatic, low CHD risk44.5%6.0% Asymptomatic, post-revascularization < 2 years after PCI, symptoms before PCI23.8%3.2% Evaluation of chest pain, low probability pt Interpretable ECG and able to exercise16.1%2.2% Asymptomatic or stable symptoms, known CAD < 1 year after cath or abnormal prior SPECT3.9%0.5% Pre-operative assessment Low risk surgery3.8%0.5 % TOTAL92.1%12.4 %

17 MOST COMMON INAPPROPRIATE INDICATIONS INDICATION % INAPPRO INDICATIONS % TOTAL STUDIES Detection of CAD ALL 6 SITES HAD #1 Asymptomatic, low CHD risk44.5%6.0% Asymptomatic, post-revascularization < 2 years after PCI, symptoms before PCI 5/6 SITES=#223.8%3.2% Evaluation of chest pain, low probability pt Interpretable ECG and able to exercise16.1%2.2% Asymptomatic or stable symptoms, known CAD < 1 year after cath or abnormal prior SPECT3.9%0.5% Pre-operative assessment Low risk surgery3.8%0.5 % TOTAL92.1%12.4 %

18 APPROPRIATENESS CATEGORY Based on Referral n = 4,792 n = 1,136 p < 0.0001 13.2% 16.1% 19.5% 70.7% 9.9%

19 APPROPRIATENESS CATEGORY Based on Referral n = 4,881 n = 1,047 p < 0.0001 13.2% 20.1% 16.0% 70.9% 10.1% 69.8%

20 FEEDBACK TO SITES

21 INAPPROPRIATE SPECT-MPI Temporal Changes Based on Site

22 CONCLUSIONS Data collection and analysis regarding appropriate use of SPECT imaging is feasible in busy community practice environment –Easy to use, point-of-ordering tool with web-based data entry –Automated determination of appropriateness –On-demand, benchmarked reports Variable rates of test appropriateness Consistent inappropriate indications –Asymptomatic, low risk patient are most frequent Feedback/education may influence on practice habits Less inappropriate testing from cardiologists than non-cardiologists

23 IMPLICATIONS Physicians and other health care professionals, working with medical societies, recognize the current healthcare environment –Active measures to optimize performance and cost-effectiveness –Preserve patient access to evaluation and treatment The development and implementation of appropriate use criteria may offer an alternative to prior authorization/pre-certification approaches –Transparency –Expanded information regarding practice habits –Facilitation of on-going quality improvement –Movement toward point-of-order application –Potential for wide-scale utilization Establishment of partnership between ACC, subspeciality societies, and health plans regarding responsible approach to medical imaging and continued emphasis on improving the quality of care

24 ACKNOWLEDGMENTS American Society of Nuclear Cardiology (ASNC) UnitedHealthcare Leadership of ACC –Especially Douglas Weaver, Ralph Brindis, Michael Wolk, Pamela Douglas, Jack Lewin, and Janet Wright Staff from ACC, NCDR, and DCRI –Notably Joseph Allen, Karen Caruth, Wenqin Pan, and Nichole Kallas

25 LIMITATIONS Non-evaluable data –Missing information –Conflicting indications Rolling recruitment with inconsistent time periods Lack of validation of computer-assigned indications –Multiple indications –Audits reveal variance Educational initiatives inconsistently applied Non-adjudicated SPECT interpretations

26 AUDIT OF COMPUTER-ASSIGNED INDICATIONS VERSUS INDEPENDENT PHYSICIAN REVIEW

27 SPECT RESULTS Based on Appropriateness Category APPROPRIATE UNCERTAIN INAPPROPRIATE p < 0.0003

28 INDICATION AND SPECT FINDINGS Most Common Inappropriate Indications INDICATION % Abnormal SPECT Detection of CAD Asymptomatic, low CHD risk27.7% Asymptomatic, post-revascularization < 2 years after PCI, symptoms before PCI54.7% Evaluation of chest pain, low probability pt Interpretable ECG and able to exercise19.7% Asymptomatic or stable symptoms, known CAD < 1 year after cath or abnormal prior SPECT63.6% Pre-operative assessment Low risk surgery25.0%

29 PROBABILITY OF CORONARY ARTERY DISEASE BASED ON AGE, GENDER AND SYMPTOMS (Diamond & Forrester) ESTIMATED n = 5,567 CALCULATED n = 6,332

30 CORONARY HEART DISEASE RISK BASED ON FRAMINGHAM CRITERIA ESTIMATED n = 5,649 CALCULATED n = 6,082

31 REASON FOR TEST Based on Appropriateness Category Overall %A %U %I % Detection of CAD/Risk stratification- Symptomatic 47.460.719.425.8 Detection of CAD/Risk stratification- Asymptomatic 9.93.817.524.4 Risk assessment- Post-revascularization 16.411.736.315.7 Assessment of viability/function 3.44.31.72.0 Risk assessment- Prior test results 12.18.016.624.2 Risk assessment- Pre-operative evaluation 8.09.52.97.8 Risk assessment- Post-ACS 2.92.15.54.3

32 ACC METHODOLOGY FOR DEVELOPMENT OF APPROPRIATE USE CRITERIA (Rand/Modified Delphi Method) Outside Review of Indications and Additional Modification Prior to Rating 1 st Round – No interaction Face-to-Face Meeting 2 nd Round – Panel interaction Literature Review and Synthesis of the EvidenceList of indications and definitionsAppropriateness Score (7-9) Appropriate (4-6) Uncertain (1-3) Inappropriate Retrospective comparison with clinical recordsProspective clinical decision aids Validation Appropriateness Determination % Use that is Appropriate, Uncertain, InappropriateIncrease Appropriateness Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method Users Manual, 2001, 4 Balanced panel comprised of different types of experts rates the indications in two rounds Writing Group Technical Panel External Reviewers Implementation Working Group


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