appropriate use criteria for coronary revascularization- updates 2012
TRANSCRIPT
Abdelkader Almanfi , MD, MRCP-UK
Texas Hear t Institute
May 9th
2013
Appropriate Use Criteria for Coronary Revascularization
Objective
Help you to use the 2012 Appropriate Use Criteria (AUC) for Coronary Revascularization to improve the care of your patients
AUC: What Did You Mean?―AUC‖ could mean Area Under the Curve (Receiver Operating Characteristic Curve;
pharmacokinetic curve) The 2009 JACC/Circulation Paper on Appropriateness Criteria for
Coronary Revascularization The 2012 Appropriate Use Criteria for Coronary Revascularization
Focused Update Bedside assessment of the appropriateness of PCI or CABG for a given
patient A score (or statistics about scores) from the NCDR CathPCI Registry
or other vendors
Appropriateness Criteria, 2009
Developed as a supplement to ACC/AHA Guideline documents.
Appropriateness criteria are designedto examine the use of diagnostic and therapeutic
proceduresto support efficient use of medical resourcesduring the pursuit of quality medical care
Patel, et al. JACC 2009; 53:530-553
Patel, et al. JACC 2009; 53:530-553
The WritingCommittee
Extensive literature review and synthesis
of the evidence
What are the known indicationsfor coronary revascularization?
- Major randomized trials- Guidelines- Other sources
Current understanding of technical capabilities and potential patient benefits of the procedures examined
Appropriateness review of ~180* common clinical scenarios encountered in everyday practice in which coronary revascularization is frequently considered
*Did not include every conceivable situation (>4,000 possible scenarios)
Appropriateness Criteria, 2009
Appropriateness Criteria: Intended to assist patients and clinicians Not intended to diminish the difficulty or uncertainty
of clinical decision making Cannot act as substitutes for sound clinical judgment
and practice experience Allow assessment of utilization patterns for a test or
procedure, including across providers
Appropriateness Criteria, 2009
Patel, et al. JACC 2009; 53:530-553
―The ACCF and its collaborators believe that an ongoing review of one’s practice using these criteria will help guide a more effective, efficient, and equitable allocation of health care resources, and ultimately, better patient outcomes.‖
Appropriateness Criteria, 2009
Patel, et al. JACC 2009; 53:530-553
Scenarios scored by a technical panel (17 members in a modified Delphi exercise) on a scale of 1-9.
Scores 7-9: Appropriate, revascularization likely to improve health outcomes or survival
Scores 4-6: Uncertain, likelihood that revascularization would improve health outcomes or survival was considered uncertain
Scores 1-3: Inappropriate, revascularization unlikely to improve health outcomes or survival
Health outcomes: symptoms, functional status, and/or quality of life
Patel, et al. JACC 2009; 53:530-553
Appropriateness Criteria:2009 Methodology
In other words
Scores 7-9: Appropriate, revascularization is generally acceptable and is a reasonable approach for the indication
Scores 4-6: Uncertain, revascularization may be acceptable and may be a reasonable approach for the indication, but more research and/or patient information is needed to classify the indication definitively
Scores 1-3: Inappropriate, revascularization is notgenerally acceptable and is not a reasonable approach for the indication
Patel, et al. JACC 2009; 53:530-553
Appropriateness Criteria:2009 Methodology
Patel, et al. JACC 2009; 53:530-553
Clin
ical P
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tati
on
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angina
STEMI
Severi
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f A
ng
ina
ASx,
CCS Class I
CCS Class IV
Isch
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Tes
ts/P
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no
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Fac
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*
None,
Low risk
High
risk
None
Max
Med
ical
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LM +
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An
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Appropriateness Criteria: Key Variables
Appropriate Use Criteria for Coronary Revascularization Focused Update 2012
Endorsed by:
AUC 2012
Reassessment of clinical scenarios felt to be affected by significant changes in the medical literature or gaps from prior criteria
A practical standard upon which to assess and better understand variability in the use of cardiovascular procedures
Patel, et al. JACC 2012; 59:
AUC 2012: The Fine Print
Significant coronary stenosis: LMCA stenosis ≥50% luminal diameter narrowing
in the worst view by visual assessment Epicardial non-LMCA stenosis ≥70% luminal
diameter narrowing in the worst view by visual assessment
“Borderline” coronary stenosis: Epicardial non-LMCA stenosis 50-60% luminal
diameter narrowing
Patel, et al. JACC 2012; 59:
Assumptions No other CAD present except as specified in the
clinical scenario. All patients are receiving standard care,
including guideline-based risk factor modification for primary or secondary prevention
Operators performing PCI or CABG have appropriate clinical training and experience and have satisfactory outcomes as assessed by quality assurance monitoring
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Assumptions PCI or CABG is performed in a manner consistent with established standards
of care. No unusual extenuating circumstances exist, e.g.,
inability to comply with antiplatelet agents do not resuscitate status patient unwilling to consider revascularization technically not feasible to perform revascularization comorbidities likely to markedly increase procedural
risk substantially
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Maximal Anti-Ischemic Medical Therapy: the use of at least 2 classes of therapies to reduce anginal symptoms
Risk of Findings on Noninvasive Testing Low-Risk (<1% annual cardiac mortality) Intermediate-Risk (1-3% annual cardiac mortality) High-Risk (>3% annual cardiac mortality)
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
High Risk Findings on Noninvasive Testing Severe resting left ventricular dysfunction (LVEF <35%) High-risk treadmill score Severe exercise left ventricular dysfunction (exercise LVEF <35%) Stress-induced large perfusion defect (particularly if anterior) Stress-induced multiple perfusion defects of moderate size Large, fixed perfusion defect with LV dilation or increased lung
uptake (thallium-201) Stress-induced moderate perfusion defect with LV dilation or
increased lung uptake (thallium-201) Echocardiographic wall motion abnormality (involving greater than
two segments) developing at low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)
Stress echocardiographic evidence of extensive ischemia
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Intermediate Risk Findings on Noninvasive Testing
Mild/moderate resting left ventricular dysfunction (LVEF = 35% to 49%)
Intermediate-risk treadmill score Stress-induced moderate perfusion defect without
LV dilation or increased lung intake (thallium-201)
Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving less than or equal to two segments
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Low Risk Findings on Noninvasive Testing Low-risk treadmill score Normal or small myocardial perfusion defect at rest
or with stress* Normal stress echocardiographic wall motion or no
change of limited resting wall motion abnormalities during stress*
* Although the published data are limited, patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting left ventricular dysfunction (LVEF <35%)
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Classification of Chest Pain Typical Angina (Definite):
Substernal chest pain or discomfort Provoked by exertion or emotional stress Relieved by rest and/or nitroglycerin
Atypical Angina (Probable):
Lacks one of the characteristics of definite or typical angina
Nonanginal Chest Pain:
Meets one or none of the typical angina characteristics
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Canadian Cardiovascular Society (CCS) Classification of Angina Pectoris
CCS I: Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.
CCS II: Slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
Canadian Cardiovascular Society (CCS) Classification of Angina Pectoris
CCS III: Marked limitations of ordinary physical activity. Angina occurs on walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace.
CCS IV: Inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.
Patel, et al. JACC 2012; 59:
AUC 2012: The Fine Print
TIMI Risk Score for Patients With Suspected Acute Coronary Syndrome
1 point per item Age ≥65 years ≥ 3 Risk Factors for CAD Diabetes mellitus; Cigarette smoking; Hypertension (BP 140/90 mm Hg or on antihypertensive
medication); Low HDL cholesterol (<40 mg/dL); Family history of premature CAD (CAD in
male first-degree relative, or father less than 55, or female first-degree relative or mother less than 65)
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
TIMI Risk Score for Patients With Suspected Acute Coronary Syndrome, continued
1 point per item
Known CAD (stenosis ≥50%) Aspirin Use in Past 7 days Severe angina (≥2 episodes within 24 hrs) ST segment deviation ≥0.5 mm Elevated Cardiac Myonecrosis Biomarkers
AUC 2012: The Fine Print
Patel, et al. JACC 2012; 59:
TIMI Risk Score for Patients With Suspected Acute Coronary Syndrome
Low Risk (0-2): 4.7-8.3% risk of death or ischemic events through 14 days
Intermediate Risk (3-4): 13.2-19.9% risk of death or ischemic events through 14 days
High Risk (5-7): 26.2-40.9% risk of death or ischemic events through 14 days
Patel, et al. JACC 2012; 59:
AUC 2012: The Fine Print
AUC 2012: What’s New15 Updated Indications
Patel, et al. JACC 2012; 59:
AUC 2012: What’s New15 Updated Indications
Patel, et al. JACC 2012; 59:
13 scenarios for acute coronary syndromes 36 scenarios for non-ACS without prior bypass
surgery 12 scenarios for non-ACS with prior bypass
surgery 8 scenarios for advanced CAD, CCS III or IV,
and/or intermediate- to high-risk findings on non-invasive testing
AUC 2012: The Whole Thing69 Categories of Indications
Patel, et al. JACC 2012; 59:
AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:
AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:
AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:
AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:
AUC 2012: At the Bedside
Patel, et al. JACC 2012; 59:
SCAI AUC 2012 Tool
SCAI AUC 2012 Tool
SCAI AUC 2012 Tool
Limitations of the AUC
―Maximal antianginal medical therapy is defined as the use of at least 2 classes of therapies to reduce anginal symptoms.‖–intolerance, allergies, resting heart rate and blood pressure are not taken into account.
Inter-rater variability in coding the results of non-invasive testing for low, intermediate and high risk.
Patel, et al. JACC 2012; 59:
Challenges in Documentation of the AUC Inputs
Insufficient primary documentation to assess CCS class (e.g., ―worsening exertional angina‖)
Lack of documentation of formal evaluation of CCS class by a cardiologist (which leads to inter-rater variability in imputing CCS class from the clinical documentation and thus difficulties with audits of CCS class against source documentation).
Improving Your AUC Results
CathPCI Registry AUC algorithm is proprietary. Nonetheless, you can improve your AUC scores by Improving clinical documentation of symptom precipitants
and non-invasive test results Formally documenting assessment of CCS class and
severity/risk of non-invasive test results (which makes life easier for your CathPCI data abstractors)
Assess AUC at the bedside prior to undertaking a coronary revascularization
Documenting thoroughly for cases rated to be of uncertain or inappropriate appropriateness
AUC 2012: In a Nutshell
The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.
The AUC are intended to evaluate overall patterns of care regarding revascularization rather adjudicating specific cases.
It is not anticipated that all physicians or facilities will have 100% of their revascularization procedures deemed appropriate.
Patel, et al. JACC 2012; 59:
The use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was felt to be appropriate (or appropriate or uncertain).
Revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:
There may be clinical situations in which a use of coronary revascularization for an indication considered to be appropriate does not always represent reasonable practice, such that the benefit of the procedure does not outweigh the risks.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:
The rating of a revascularization indication as inappropriate or uncertain should not preclude a provider from performing revascularization procedures when there are patient- and condition-specific data to support that decision. Indeed, this may reflect optimal clinical care, if supported by mitigating patient characteristics.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:
Uncertain indications require individual physician judgment and understanding of the patient to better determine the usefulness of revascularization for a particular scenario. The ranking of uncertain (4 to 6) should not be viewed as excluding the use of revascularization for such patients.
AUC 2012: In a Nutshell
Patel, et al. JACC 2012; 59:
When a procedure is classified as ―Uncertain‖ it generally means one of two things
1. There was insufficient clinical information in the scenario. For example:
What would you do if:
This were an 85 y/o patient with typical age-related limitations?
This were a 35 y/o firefighter?
Uncertainty about “Uncertain”
When a procedure is classified as ―Uncertain‖ it generally means one of two things
1. There was insufficient clinical information in the scenario.
2. There is not a substantial literature base upon which to make a firm recommendation
No randomized trials on: This were an 85 y/o patient with typical age-related limitations?This were a 35 y/o firefighter?
Uncertainty about “Uncertain”
When a procedure is classified as ―Uncertain‖ it generally means one of two things
1. There was not enough clinical information in the scenario.
2. There is not a substantial literature base upon which to make a firm recommendation
Is there literature that identifies the correct treatment for this?
Uncertainty about “Uncertain”
JAMA June 6, 2011
Appropriateness: How do we rate?
NCDR Data July 1, 2009 thru Sept 30, 2010
Appropriateness mapping done by MAHI
500,154 PCI procedures at 1091 facilities
355,417 (71%) Acute:
STEMI, NSTEMI, High-risk UA
144,737 (29%) Non-acute:
Appropriateness: How do we rate?
From: WSJ July 6, 2011
Uncertainty about “Uncertain”
Did the Media Get it Right?
Did the Media Get it Right?
Did the Media Get it Right?
Did the Media Get it Right?
Variation in Hospital Rates of Inappropriate PCIs for Non-Acute Indications
JAMA June 6, 2011
What Can You Do?
Make certain you understand ―uncertain‖ More importantly, make sure those entering your NCDR
data are entering variables correctly Develop an action plan to evaluate patients graded as
inappropriate and uncertain NCDR facilities can get a detailed listing of patients with these
classifications.
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