multi-center assessment of the utilization of spect myocardial perfusion imaging using the accf...
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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 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 SpecialistsWinfield, IL
Chairman, ACCF/UHC SPECT-MPI Pilot Study
Late Breaking Clinical TrialsAmerican College of Cardiology Scientific Sessions 2009
March 29, 2009
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Presenter Disclosure Information
Robert C. Hendel, MD
The following relationships exist related to this presentation:
Consulting PGx Health ModestAstellas Pharma ModestGE Healthcare Modest
Research support Astellas ModestGE Healthcare Modest
Organizational ACC (Appropriate Use Criteria Task Force)
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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
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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
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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
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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
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METHODSSites of Pilot
State Locale # MD’s
# patients enrolled
Site 1 FL Urban 17 635
Site 2 FL Urban 7 1293
Site 3 WI Rural 15 1597
Site 4 FL Urban 20 1570
Site 5 OR Suburban 17 328
Site 6 AZ Suburban 9 938
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METHODSEnrollment Periods
3/1/08 8/15/08 2/28/0910/15/08
Period 1 Period 2 Period 3
On-demandReport
PaperReport
SITE 123456
1 SITE 23456
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RESULTSPatient 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%
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RISK ASSESSMENTAutomated Calculation and Indication Assignment
5%
40%
49%
6%
Very LowLowModerateHigh
66%9%
25%
LowModerateHigh
SYMPTOMATIC PATIENTS(Diamond & Forrester)
ASYMPTOMATIC PATIENTS(Framingham; CHD Risk)
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APPROPRIATENESS CLASSIFICATION(n = 6,351)
Appropriate66%
Uncertain14%
Inappropriate13%
Unclassifed7%
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APPROPRIATENESS CLASSIFICATION Elimination of Unclassified (n = 5,928)
Appropriate71%
Uncertain15%
Inappropriate14%
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APPROPRIATENESS CLASSIFICATION Based on Site
0%
20%
40%
60%
80%
100%
Site 1 Site 2 Site 3 Site 4 Site 5 Site 6
Inappropriate
Uncertain
Appropriate
n = 578 1200 1448 1448 322 932
InappropriateRange: 4-22%
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APPROPRIATENESS CATEGORYBased on Patient Factors
0%
20%
40%
60%
80%
100%
Age >65 Age ≤65 Men Women
Inappropriate
Uncertain
Appropriate
p < 0.0001 p = 0.039n = 3,046 2,882 3,468 2,460
9.8% 19.3% 13.6% 15.5%
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MOST COMMON “INAPPROPRIATE” INDICATIONS
INDICATION
% INAPPRO INDICATIONS
% TOTAL STUDIES
Detection of CADAsymptomatic, 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 ptInterpretable 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 assessmentLow risk surgery 3.8% 0.5 %
TOTAL 92.1% 12.4 %
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APPROPRIATENESS CATEGORY Based on Referral
0%
20%
40%
60%
80%
100%
Cardiologist Non-Cardiologist
Inappropriate
Uncertain
Appropriate
n = 4,792 n = 1,136
p < 0.0001
13.2%
16.1%
19.5%
70.7% 70.7%
9.9%
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APPROPRIATENESS CATEGORY Based on Referral
0%
20%
40%
60%
80%
100%
Within Practice Outside Practice
Inappropriate
Uncertain
Appropriate
n = 4,881 n = 1,047
p < 0.0001
13.2% 20.1%
16.0%
70.9%
10.1%
69.8%
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FEEDBACK TO SITES
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INAPPROPRIATE SPECT-MPITemporal Changes Based on Site
0
5
10
15
20
25
30
Period 1 Period 2 Period 3
% I
napp
ropr
iate
Site 1 Site2Site 3Site 4
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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
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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
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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
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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
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AUDIT OF COMPUTER-ASSIGNED INDICATIONS VERSUS INDEPENDENT PHYSICIAN REVIEW
71%
15%
14%
AgreePartial agreeDisagree
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SPECT RESULTSBased on Appropriateness Category
40.3%
59.7%
NormalAbnormal
43.6%
56.4%
NormalAbnormal
34.3%
65.7%
NormalAbnormal
APPROPRIATE
UNCERTAIN
INAPPROPRIATE
p < 0.0003
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INDICATION AND SPECT FINDINGSMost Common “Inappropriate” Indications
INDICATION
% Abnormal SPECT
Detection of CADAsymptomatic, low CHD risk 27.7%
Asymptomatic, post-revascularization< 2 years after PCI, symptoms before PCI 54.7%
Evaluation of chest pain, low probability ptInterpretable ECG and able to exercise 19.7%
Asymptomatic or stable symptoms, known CAD< 1 year after cath or abnormal prior SPECT 63.6%
Pre-operative assessmentLow risk surgery 25.0%
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PROBABILITY OF CORONARY ARTERY DISEASE BASED ON AGE, GENDER AND SYMPTOMS
(Diamond & Forrester)
Very LowLowModerateHigh
Very LowLowModerateHigh
ESTIMATEDn = 5,567
CALCULATEDn = 6,332
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CORONARY HEART DISEASE RISKBASED ON FRAMINGHAM CRITERIA
66%9%
25%
LowModerateHigh
32%
32%
36%
LowModerateHigh
ESTIMATEDn = 5,649
CALCULATEDn = 6,082
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REASON FOR TESTBased on Appropriateness Category
Overall % A % U % I %Detection of CAD/Risk stratification-Symptomatic
47.4 60.7 19.4 25.8
Detection of CAD/Risk stratification-Asymptomatic
9.9 3.8 17.5 24.4
Risk assessment- Post-revascularization
16.4 11.7 36.3 15.7
Assessment of viability/function 3.4 4.3 1.7 2.0
Risk assessment- Prior test results
12.1 8.0 16.6 24.2
Risk assessment- Pre-operative evaluation
8.0 9.5 2.9 7.8
Risk assessment- Post-ACS
2.9 2.1 5.5 4.3
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ACC METHODOLOGY FOR DEVELOPMENT OF APPROPRIATE USE CRITERIA
(Rand/Modified Delphi Method)
Outside Review of Indications and Additional Modification Prior to Rating
1st Round – No interaction
Face-to-Face Meeting
2nd Round – Panel interaction
Literature Review and Synthesis of the Evidence List of indications and definitions
Appropriateness Score
(7-9) Appropriate
(4-6) Uncertain
(1-3) Inappropriate
Retrospective comparison with clinical records Prospective clinical decision aids
Va
lid
ati
on
Ap
pro
pri
ate
ne
ss
De
term
ina
tio
n
% Use that is Appropriate, Uncertain, Inappropriate Increase Appropriateness
Adapted from Fitch K, et al. The RAND/UCLA Appropriateness Method User’s Manual, 2001, 4
Balanced panel comprised of different types of experts rates the indications in two roundsBalanced panel comprised of different types of experts rates the indications in two rounds
Writing Group
Technical Panel
External Reviewers
Implementation Working Group