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. The following relationships exist related to this presentation:
Presenter Disclosure Information
Robert C. Hendel, MD
The following relationships exist related to this presentation:
Consulting PGx Health Modest
Astellas Pharma Modest
GE Healthcare Modest
Research support Astellas Modest
Organizational ACC (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
The ACC is focusing on quality in cardiac imaging for the following reasons:1
There is unprecedented focus by professional societies, governmental agencies and payers,
on assessment and improving the quality of cardiac imaging
There has been an explosive growth of cardiovascular imaging in the United States
There continues to be substantial regional variation in utilization
The true nature of utilization is not known
In my view, clinicians, patients and payers are seeking guidance on how to proceed.
1.Patel Mr, Spertus JA, Brindis, RG et al. ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging, J Am Coll Cardiol. 2005; 46:

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
On-demand reports
Periodic overall and site-specific summaries provided
Audit of automated indication assignments

6. DATA COLLECTION FORM Front page Back page
Patient Demographics
History & Risk Factors,
Prior procedures & Tests
Back page
Current Study
Reference section
Designed to be completed in one minute or less
Start with paper data collection form
Designed to be completed in one minute or less

8. METHODS Sites of Pilot State Locale # MD’s # patients enrolled Site 1FL
Urban 17
635
Site 2 7
1293
Site 3 WI
Rural 15
1597
Site 4 20
1570
Site 5 OR
Suburban
328
Site 6 AZ 9
938

9. METHODS Enrollment Periods
3/1/08
8/15/08
10/15/08
2/28/09
SITE 1 2 3 4 5 6
1 SITE 2 3 4 5 6
Period Period Period 3
On-demand
Report
Paper
Report

10. RESULTS Patient Characteristics (n = 6,351)
Age, years
65.7±11.8
Gender, male
3,729
58.7%
Diabetes
1,446
22.3%
Smoker
743
11.7%
Hypertension
4,856
76.7%
Hyperlipidemia
4,616
72.9%
Prior PCI
1,806
36.1%
Prior CABG
945
19.7%
Asymptomatic
2,414
38.0%

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
Inappropriate
Range: 4-22%
n =

15. APPROPRIATENESS CATEGORY Based on Patient Factors
9.8%
19.3%
13.6%
15.5%
n = , , , ,460
p < p = 0.039

16. MOST COMMON “INAPPROPRIATE” INDICATIONS
% INAPPRO INDICATIONS
% TOTAL STUDIES
Detection of CAD
Asymptomatic, low CHD risk
44.5%
6.0%
Asymptomatic, post-revascularization
< 2 years after PCI, symptoms before PCI
23.8%
3.2%
Evaluation of chest pain, low probability pt
Interpretable ECG and able to exercise
16.1%
2.2%
Asymptomatic or stable symptoms, known CAD
< 1 year after cath or abnormal prior SPECT
3.9%
0.5%
Pre-operative assessment
Low risk surgery
3.8%
0.5 %
TOTAL
92.1%
12.4 %

17. APPROPRIATENESS CATEGORY Based on Referral
13.2%
19.5%
16.1%
9.9%
70.7%
70.7%
n = 4, n = 1,136

18. APPROPRIATENESS CATEGORY Based on Referral
13.2%
20.1%
16.0%
10.1%
70.9%
69.8%
n = 4, n = 1,047

19. FEEDBACK TO SITES

20. INAPPROPRIATE SPECT-MPI Temporal Changes Based on Site

21. 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

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 and are taking active measures to optimize performance and cost-effectiveness, while preserving patient access to evaluation and treatment procedures
The development and implementation of AUC 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, imaging subspeciality society, and health plan regarding responsible approach to medical imaging and continuing emphasis on improving the quality of care

24. ACKNOWLEDGMENTS American Society of Nuclear Cardiology (ASNC)
Support from 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