EDITORIAL POINT OF VIEW The revolution and evolution of appropriateness in cardiac imaging Robert C. Hendel, MD, FACC, FAHA, FASNC The excellence of a gift lies in its appropriateness . . . . Charles Dudley Warner, “Eleventh Study,” Backlog Studies, 1873 Cardiovascular imaging provides unquestioned value for patient care and is tightly woven into the fabric of modern clinical practice. However, in recent years the “expense” of procedures including single photon emission computed tomography (SPECT) myocardial perfusion imaging, echocardiography, cardiac computed tomography, and cardiac magnetic resonance has raised concern not only about the direct fiscal impact of these techniques but also related to exposure of patients to procedural risks as well as for downstream testing and unnecessary therapeutic interventions. The growth rates of medical imaging continue to outpace other medical services.1 In addition, substantial regional variation in imaging procedures is present even after adjustment for demographics and comorbidities.2 These factors have raised concern about self-referral and testing for financial gain. However, there are no data regarding whether imaging is being actually misused or overutilized. Within the past several years, a significant transformation has occurred within the cardiovascular imaging community. Quality in imaging has become a critical issue, stimulating leaders from industry, professional societies, practicing physicians, and health plans to define the concept and develop metrics.3 Test and patient selection has become one of the key parameters, providing the impetus for the creation of appropriateness criteria. Although guidelines and standards have been developed for the performance and application of imaging procedures, appropriateness criteria serve to define what constitutes a reasonable use for a procedure within the context of a specific clinical indication.4 What would lead to the performance of cardiac testing in an “inappropriate fashion”? Although payers From Midwest Heart Specialists, Winfield, Ill. Reprint requests: Robert C. Hendel, MD, FACC, FAHA, FASNC, 1 Kingswood Ct, Riverwoods, IL 60015; rhendel@midwestheart. com. J Nucl Cardiol 2008;15:494-6. 1071-3581/$34.00 Copyright © 2008 by the American Society of Nuclear Cardiology. doi:10.1016/j.nuclcard.2008.05.002 494
usually cite greed and financial incentives for physicians, other explanations are present, including ignorance of current standards and guidelines, as well as a reluctance to accept such guidelines because of a perception of interfering with clinical practice and/or professional judgment. In addition, patients may come to expect testing procedures, and when these are not performed on a routine clinical basis, they wonder whether the physician is “depriving” them of an important procedure to save money. However, one of the most common explanations offered for ordering “inappropriate” cardiac tests is concern about the medicolegal consequences of not performing the test and potentially failing to make a diagnosis or treat an occult problem. This latter concern may only be addressed by far-reaching legal reforms. However, changing the local standard, perhaps by ordering and performing testing in an appropriate fashion, could in the long run alter this malpractice environment. Appropriateness criteria were developed as an outgrowth from dialog with regulators and health plans concerned about the spiraling cost of medical imaging but with an understanding that efforts should not result in indiscriminant procedural volume reduction. Rather, the focus should be on “the right test, at the right time, for the right patient.” The appropriateness criteria were developed by use of an established methodology, modified to fit the needs of medical decision making in the current environment.4 The creation of appropriateness criteria has involved a large amount of time, money, and expertise but has resulted in a carefully vetted expert consensus of procedural appropriateness based on medical literature and published guidelines, whenever possible. This has only been possible with the cooperation of key organizations such as the American College of Cardiology, American Heart Association, and American College of Radiology, working in conjunction with a large number of subspecialty organizations, including the American Society of Nuclear Cardiology. Thus far, criteria have been published for SPECT myocardial perfusion imaging,5 stress echocardiography,6 transthoracic and transesophageal echocardiography,7 and cardiac computed tomography and magnetic resonance.8 Within the next several months, appropriateness criteria will be published extending beyond cardiac imaging, focusing on cardiac surgery and percutaneous coronary intervention. But perhaps the most valuable and certainly
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controversial appropriateness criteria will be assembled later this year, in the context of a multimodality panel, charged with considering multiple different diagnostic modalities for specific clinical indications. The criteria are by no means perfect, as all who have examined and used them have discovered. Not all clinical scenarios are included, leading to potential gaps in application. The language and structure of the indications are cumbersome and sometimes lacking clarity. In addition, the appropriateness criteria are unwieldy to use and do not, at the current time, offer a clear decision tree to follow. It is with close review and experience using the criteria, however, that improvements may be made. The development of appropriateness criteria has been intended from the onset to be a dynamic process. Published data regarding the use of existing criteria serve as information to revise these documents, and the criteria themselves serve to highlight areas where more clinical research is needed.9-11 Furthermore, practitioners, health plans, and medical organizations may provide critical information regarding clarifying indications or suggesting new ones, as well as pointing out new data that should be considered in the evaluation and ranking of the clinical scenarios. The American Society of Nuclear Cardiology has done an exemplary job in providing information to be considered for an update of the SPECT appropriateness criteria, which is currently in progress.12 Although most consensus documents serve to guide practitioners, it is the evaluation and implementation phase of the appropriateness criteria “movement” that offers true potential for impacting test utilization. Many abstracts and a few articles have been published demonstrating that appropriateness can be tracked at the point of service and that the use of the appropriateness criteria is feasible, although this is not necessarily an easy task. Appropriateness may be evaluated by use of the limited number of developed criteria for approximately 90% of all studies.9-11 Although chart audits provide the highest caliber of data, this is impractical for most clinical settings, leading to the development of tools for prospective data collection, including the use of a Web-based form. Pilot studies are under way, such as the one that partners the American College of Cardiology with United Healthcare, which will attempt to evaluate testing patterns at 10 sites of varying sizes and locations. This pilot study is being done in lieu of a prior notification/ precertification program, thereby providing a potential alternative to utilization management by a radiology benefits manager (RBM).12 RBMs and precertification have already had a great impact on the ordering of imaging procedures but largely because of indiscriminant volume reduction, which is done in a nontransparent fashion, often with the use of unique algorithms based only in part on appropriateness criteria and clinical
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guidelines. Furthermore, the process is often timeconsuming and expensive for the practice, and the use of RBMs removes money from the health care system.13 The use of physician-developed appropriateness criteria and the tracking of utilization appear to be a far better option, which also permits education and an opportunity to improve quality in imaging. Although we are still early in the evaluation phase of test utilization, it appears that roughly 10% to 18% of studies performed may be categorized as inappropriate. However, the majority of these inappropriate examinations are performed for a few common indications.9,10 Therefore educational efforts may be directed at reducing imaging within specific settings, such as evaluation before low-risk surgical procedures or for the detection of ischemic heart disease in a low-risk, asymptomatic patient. We have also begun to understand that the type of practitioner may impact test ordering (ie, cardiologist vs primary care). Preliminary data have shown that the ordering of SPECT studies may be less appropriate when emanating from a primary care physician,8 which would likely stimulate a dialog between the cardiac imaging laboratory and the clinician, as well as focused educational efforts. Furthermore, this emphasizes the need for continued/expanded collaboration with internal medicine and family practice groups to work together for improved utilization of imaging resources. How appropriateness is best monitored is unclear, as both “point-of-service” data collection and “point-ofordering” data collection provide worthwhile features. The point-of-service approach permits more optimal and comprehensive data collection involving the test parameters and patient information, and the data are collected by a health care professional with knowledge of heart disease. This approach is likely ideally suited for quality assessment programs and the evaluation of physician performance, as well as providing input into the process of criteria revision. Data collection at the point of ordering encourages a test to be requested for a clearly identifiable indication and permits maximal feedback, in an immediate fashion, to the clinician ordering the procedure, thereby serving as a decision support instrument. Tools such as this may take the form of a personal digital assistant– based appropriateness calculator, such as the one currently available for SPECT imaging.14 Appropriateness criteria and their use will continue to evolve. New criteria will be developed and existing criteria updated on a frequent basis, so as to allow for incorporation of new data. The indications will be re-examined with a goal of covering a greater number of studies but also with an eye toward improving clarity. Additional emphasis will be placed on the use of serial testing, as practices such as the “annual SPECT” examination are not likely warranted and repetitive testing is
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of tremendous concern for health plans. Furthermore, redundancy will likely be a continued focus, as performing more than one test for a specific indication is not likely necessary or efficient. Finally, the ability to evaluate appropriateness of diagnostic and therapeutic procedures will permit patient selection factors and the results of cardiac imaging to be linked directly with patient outcome, likely through registries that incorporate longitudinal (follow-up) data. Technologic advances have forever changed the practice of modern medicine. However, self-examination of how we use imaging procedures is critical, as only those with experience in clinical medicine can understand how these techniques should be applied. Information gleaned from cardiac imaging is truly a gift that may result in improved care for our patients but with the understanding, as stated by Charles Dudley Warner, that the true value of imaging may be realized only by its appropriate utilization.
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Acknowledgment The author has indicated he has no financial conflicts of interest.
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References 1. Report to the Congress: Medicare payment policy. Washington, DC: Medicare Payment Advisory Commission; 2007. 2. Wennberg JE, Wennberg D. The Dartmouth atlas of cardiovascular health care. Hanover (MH): American College of Cardiology, Society of Thoracic Surgeons, Maine Medical Center, and Center for Evaluation Clinical Science, Dartmouth Medical School; 2000;1000. 3. Douglas P, Iskandrian AE, Krumholz HM, Gillam L, Hendel R, Jollis J, et al. Achieving quality in cardiovascular imaging: Proceedings from the American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging. J Am Coll Cardiol 2006;48:2141-51. 4. Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas PS, Peterson ED, et al; American College of Cardiology Foundation.
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ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol 2005;46:1606-13. Brindis RG, Douglas PS, Hendel RC, Peterson ED, Wolk MJ, Allen JM, et al. ACCF/ASNC appropriateness criteria for singlephoton emission computed tomography myocardial perfusion imaging (SPECT MPI) [published erratum appears in J Am Coll Cardiol 2005;46:2148-50]. J Am Coll Cardiol 2005;46:1587-605. Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography. J Am Coll Cardiol 2008;51:1127-47. Douglas PS, Khandheria B, Stainback RF, Weissman NJ. ACCF/ ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography. J Am Coll Cardiol 2007;50:187-204. Hendel RC, Patel MR, Kramer CM, Hendel RC, Carr JC, Gerstad NA, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. J Am Coll Cardiol 2006;48:1475-97. Hendel R, Brindise J, Davis J, Cahill J. A pilot study for the evaluation of the appropriateness of SPECT myocardial perfusion imaging [abstract]. J Nucl Cardiol 2007;14:S75. Gibbons RJ, Miller TD, Hodge D, Urban L, Araoz PA, Pellikka P, et al. Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center. J Am Coll Cardiol 2008;51:1283-9. Mehta R, Agarwal S, Chandra S, Ward RP, Williams KA. Evaluation of the American College of Cardiology Foundation/ American Society of Nuclear Cardiology appropriateness criteria for SPECT myocardial perfusion imaging. J Nucl Cardiol 2008; 15:337-44. Ward RP, Al-Mallah MH, Grossman GB, Hansen CL, Hendel RC, Kerwin TC, et al; American Society of Nuclear Cardiology. American Society of Nuclear Cardiology review of the ACCF/ ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). J Nucl Cardiol 2007;14:e26-38. Hendel RC. Utilization management of cardiovascular imaging: Pre-certification and appropriateness. JACC Cardiovasc Imaging 2008;1:241-8. SPECT MPI appropriateness criteria decision support tool. Available from: URL: http://www.acc.org/qualityandscience/clinical/ spect_tool.htm. Last accessed May 13, 2008.
