Disclosures. The Doctor in 2012: Quality, Accountability and Cost 5/30/2012. Challenges for the CV Profession

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1 Defining Appropriate Use of Percutaneous Coronary Revascularization in th Annual ACC Oregon Chapter Cardiovascular Symposium June 3, 2012 Ralph Brindis, MD, MPH, MACC, FSCAI Senior Advisor for Cardiovascular Disease, N. Cal. Kaiser Permanente Clinical Professor of Medicine, UCSF Past President, American College of Cardiology Challenges for the CV Profession Changes in CV Practice & Health Care Reform Demand for Measurement of Quality Demand for Public Reporting & Transparency Demand for Assuring Responsible CV Innovation Diffusion Demand for Appropriate Use of CV Care Disclosures The Doctor in 2012: Quality, Accountability and Cost I am a Recovering Interventional Cardiologist Sir Luke Fildes, 1887, The Tate Museum, London Societal Perceptions of Clinicians Knight or Knightess??? 1

2 Societal Perceptions of Clinicians Knaves??? If Clinicians are Knaves Policy, management and educational efforts designed to combat and work against clinicians and not for them Self-interest/financial gain first; patients secondary Need rewards and incentives to motivate Monitoring for abuse, fraud and waste required Learn new techniques/procedures for personal gain Research for self-glorification and narcissism Health care system functions in spite of not due to them Regulations guard against malfeasance and need for public protection Jain & Cassel JAMA 2010;304: Societal Perceptions of Clinicians Clinicians viewed as Knaves & Pawns NOT Knights - Implications Behavior tied to rising healthcare costs and increased scrutiny over quality of care: Clinician viewed an obstacle not an enabler to functioning health care system Pawns??? Rather than by our professional ethic, need to be guided strict regulations or incentive payments If Clinicians are Knights Knighthood the definition of Professionalism Stewardship for Healthcare system in our hands Trusted to practice Appropriate Use of resources Champion of patients and policies to support our work Save and improve lives, financial gain is secondary Continuing education and clinical and basic research Respected advisor for policy and payment when policy affects health of public Clinicians viewed as Knaves & Pawns NOT Knights - Implications Views of unwarranted variations in care, evidence of waste and occasionally fraud The modern clinician in the United States now regarded at times as a Knave or a Pawn - rather than a Knight!! Jain & Cassel JAMA 2010;304:

3 Interventional Cardiology Despite All the Advances in Interventional Cardiology During the Past 33 years... "Most [cardiologists] haven't voluntarily incorporated the Courage criteria into their practice. What's going to continue to drive practice is reimbursement. William Boden, MD, FACC (WSJ, 2/11/10) "Bill Boden has been telling me, we're looking at a potential of $8 billion in savings," across the country Cynthia Ambres, the chief medical officer of HealthNow New York Inc. (WSJ, 2/11/10) We Have an Image Problem Variation in Care PCI Rates per 1,000 Medicare Enrollees ( ) Redding, CA McAllen, TX to 38.1 (63) 11.5 to < 13.5 (53) 10.0 to < 11.5 (75) 8.5 to < 10.0 (53) 3.5 to < 8.5 (62) Not Populated Bad News Gets All the Press Attention Variation in the Use of PCI vs. CABG February 4, 2009 US average is 2.6 PCIs for each CABG 3

4 Donald Berwick, MD Was your Stent Unnecessary? Past President and CEO, Institute for Healthcare Improvement Administrator, CMS: 7/10 12/11 Unintended variation is stealing healthcare blind 20-30% of health spending is waste with no benefit to patients, because of overtreatment, failure to coordinate care, administrative complexity and fraud A Poignant Example of Overuse in CABG Redding, CA Did Dr. Oz Get it Right? 50% of all PCIs are inappropriate Decision Making in PCI: Cascade Effect The Patient INFLUENCES ON PATIENTS Symptoms Quality of Life Patient anxiety Expectations Founded and unfounded Asymptomatic screening Family member/friend with CAD Celebrity Tim Russert Public awareness campaigns Media reports new tests/studies Financial accountability Costs and co-pays PATIENT PCP CARDIOLOGIST SELF- REFERRAL Adapted from: Lin and Redberg, Archives Int Med

5 Patient Expectations About Elective PCI 52 consecutive patients scheduled for first elective PCI completed semi-structured questionnaire prospectively Do you think the angioplasty will prevent a heart attack? Yes 75% Do you think the angioplasty will help you live longer? Yes 71% Holmboe et al. J Gen Intern Med 2000;15:632. John F. Kennedy in a 1959 campaign speech: When written in Chinese the word crisis is composed of two characters. One represents danger, and the other represents opportunity Physician Decision Making in PCI: Cascade Effect PATIENT Appropriate Use Criteria INFLUENCES ON PCPs Fear of missing a lesion Perception of patient anxiety and expectations Medicolegal liability Uncertainty about best treatment leads to referral Lin and Redberg, Archives Int Med 2007 PCP CARDIOLOGIST PCI SELF-REFERRAL TESTING & REFERRAL CATHETERIZATION INFLUENCES ON CARDIOLOGISTS Fear of missing a lesion Perception of patient anxiety and expectations Belief in the open artery hypothesis and the benefits of PCI Oculo-stenotic reflex Medico-legal liability Because: 1)There are continuing and reasonable questions about what we do 2)If we don t do this,..... someone else will 3)We need to be at the table and not on the menu!!!!!!!!! J Am Coll Cardiol 2012 Available at Potential Impact of Inappropriate PCI Why? 700,000 PCI/year in US 5% inappropriate and 12% uncertain (NCDR) 25% of uncertain PCI are? inappropriate Professional Responsibility Commitment to Quality We can do it better than anyone else >200 deaths avoidable by eliminating inappropriate PCI Components of quality include appropriateness of case selection A quality program performs appropriately selected procedures ACC/AHA/SCAI PCI Guidelines 5

6 Right Patient High Quality Cardiovascular Procedures Patient Preferences Appropriate Use Criteria Clinical Guidelines Right Procedure Decision Ongoing trials and evidence Right Procedure Execution Quality Metrics Public Reporting Right Outcome Performance Measures Value equation for cardiovascular procedures was the right procedure done in the right way with the right outcome in a timely fashion? Measures (AUC / Outcome Measures) ACC AUC Goals Where practice patterns of individuals and/or hospitals routinely conflict with AUC ratings, further evaluation and education should be considered Ultimate objective of AUC is to encourage cardiologists to take leadership and provide direction to optimize quality and safety of care and lower cost even when improving health outcomes Opportunities for cost savings are obvious What are Appropriateness Criteria? Development of CPG s, Performance Measures, and Appropriate Use Documents Antman, Antman, Circulation Circulation 2009:119: Define what to do, when to do, and how often to do in the context of local care environments combined with patient and family preferences and values Address misuse, overuse and underuse Connected to guideline content Imply a level of detail and complexity that extends beyond the current recommendations ACC AUC Goals Partner with clinicians, health plans, policymakers and payers for rational/fair use and reimbursement for CV Dx and Rx Blend evidence-base and clinical experience data, congruent with CPGs Recognize that some ambiguity is intrinsic to clinical decision making AUC is not a substitute for sound clinical judgment or patient preference Steward equitably and efficiently limited U.S. health care resources Appropriateness Use Criteria Developed Using a Modified Rand/Delphi Methodology Define Appropriateness for Coronary Revascularization Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure 6

7 Developing the Appropriateness Use Criteria The Writing Committee The Technical Panel Nominated by professional societies Selected for balance by the writing committee and Task Force 4 interventional cardiologists 4 CT surgeons 8 cardiologists 1 Health plan officer Define appropriateness Preliminary CPG & literature search Assumptions & definitions Developed 180 clinical scenarios Scenarios critiqued by all organizations Scenarios modified and improved & In-depth literature, CPG search Most examine the appropriateness of revascularization Low-Risk Findings on Noninvasive Imaging Study And Asymptomatic (Patients Without Prior Bypass Surgery) Non-invasive testing Symptoms/Rx Burden of disease Appropriateness Definitions Appropriate rating Definite or Probable benefit of PCI for the indication Clinical Scenarios Patients without prior CABG Class I or II, high risk findings regardless of med Rx Intermediate risk findings, severe Sx or max Rx Revascularization = Uncertain rating Possible benefit of PCI for the indication Inappropriate rating Unlikely benefit for the indication Framework for Decision Making STEMI Five Core Variables Class IV High risk Max LM + 3v CAD A Clinical Scenarios Patients without prior CABG Class III or IV, high risk findings regardless of med Rx = Revascularization STABILITY SYMPTOMS ISCHEMIA MEDICAL Rx ANATOMY U Stable angina Class I ASx None Low risk None No sig. CAD I 7

8 Advanced CAD Method of Revascularization Angina Class III, and/or evidence of intermediate or high risk non-invasive features Note: 2009 ratings created pre SYNTAX AUC And Revasc ISAR Left Main Update Challenges with Appropriateness Use Ratings Rely on collection of currently unavailable clinical data to map patients to appropriateness ratings Can the data always be collected? Can patients be mapped to the prototypical scenarios? Still being validated - AUC implementation will provide pragmatic, observational research opportunities to study outcomes in specific populations No data yet demonstrating equal, improved, or worse outcomes with AUC implementation Over-Simplification of Clinical Reality Currently, 198 clinical scenarios Do not capture unique patient and coronary anatomic factors If age, DM, severe CKD added more than 2,000 clinical scenarios impractical to implement AUC are a test metric and will be refined Optimal rate is not necessarily 0% 8