2/26/2013. Appropriateness Use Criteria (Drilldown) Disclosures. Tony Hermann has nothing to disclose. Mark Hutcheson has nothing to disclose

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1 Appropriateness Use Criteria (Drilldown) Disclosures Tony Hermann has nothing to disclose Mark Hutcheson has nothing to disclose Connie Anderson has nothing to disclose Issam Moussa has nothing to disclose Objectives: Identify the patient population for AUC rating Describe impact of key variables on the AUC score Demonstrate understanding of AUC classifications A, U, I using the Audience Response System Identify tools/resources that can assist in AUC evaluation 1

2 AUC Classifications Median Score 7 to 9 Appropriate procedure for specific indication (procedure is generally acceptable and is a reasonable approach for the indication). Median Score 4 to 6 Uncertain for specific indication (procedure may be generally acceptable and may be a reasonable approach for the indication). Uncertainty implies that more research and/or patient information is needed to classify the indication definitively. Median Score 1 to 3 Inappropriate procedure for that indication (procedure is not generally acceptable and is not a reasonable approach for the indication). Table 1. Patients w/ ACS TIMI Risk Score applies to UA/NSTEMI AUC Indications 9 & 10 2

3 TIMI Risk Score Calculator AUC Case Scenario Pt presents to urgent care facility with chest pain STEMI diagnosed 0907 Transferred to 2nd facility for PCI Ptarrived at 2nd 1300, STE resolved Ptadmitted to ICU. Mild 2311 Taken to cath lab for eval,pt stable No HF, PCI of Mid RCA ARS Question #1 How will this PCI be classified for the AUC? Appropriate Median Score 7-9 Uncertain Median Score 4-6 Inappropriate Median Score 1-3 3

4 AUC Evaluation Process Step 1 Which best describes the patient? STEMI, initial presentation NSTEMI, initial presentation STEMI or NSTEMI, S/P successful PCI of the culprit artery Unstable angina without MI STEMI diagnosed 0907 Transferred to 2nd facility for PCI Ptarrived at 2nd 1300, STE resolved Ptadmitted to ICU. Mild 2311 Taken to cathlab for eval,pt stable No HF, PCI of Mid RCA AUC Evaluation Process step #.. Is there evidence of cardiogenic shock? YES NO Did patient receive fibrinolytic therapy? YES NO STEMI diagnosed 0907 Transferred to 2nd facility for PCI Ptarrived at 2nd 1300, STE resolved Ptadmitted to ICU. Mild 2311 Taken to cathlab for eval,pt stable No HF, PCI of Mid RCA AUC Evaluation Con t Hours from symptom onset? <=12 hours hours STEMI diagnosed 0907 Ptarrived at 2nd 1300, STE resolved Ptadmitted to ICU. Mild 2311 Taken to cathlab for eval,pt stable No HF, PCI of Mid RCA Does the patient have severe HF, persistent ischemic symptoms, or hemodynamic or electrical instability? YES NO 4

5 ARS Question Pt presents to urgent care facility with chest pain STEMI diagnosed 0907 Transferred to 2nd facility for PCI Ptarrived at 2nd 1300, STE resolved Ptadmitted to ICU. Mild 2311 Taken to cath lab for eval,pt stable No HF, PCI of Mid RCA How will this PCI be classified for the AUC? U I A AUC Case Scenario 45 y/o Ptpresents to ED w/ complaint of nausuea Father passed of age 52 BP 118/78, no meds No STE, Troponin I 3.2 Dx cath revealed 90% LCX PCI performed ARS Question #2 How will this PCI be classified for the AUC? Appropriate Median Score 7-9 Uncertain Median Score 4-6 Inappropriate Median Score 1-3 5

6 AUC Evaluation Process Step 1 Which best describes the patient? STEMI, initial presentation NSTEMI, initial presentation STEMI or NSTEMI, S/P successful PCI of the culprit artery Unstable angina without MI 45 y/o Ptpresents to ED w/ complaint of nausea Father passed of age 52 BP 118/78, no meds No STE, Troponin I 3.2 AUC Evaluation Process step #.. Is there evidence of cardiogenic shock? YES NO Do you know the level of shortterm risk of death or nonfatal MI (e.g., TIMI ACS Risk Score)? YES NO 45 y/o Ptpresents to ED w/ complaint of nausea Father passed of age 52 BP 118/78, no meds No STE, Troponin I 3.2 Dxcathrevealed 90% LCX PCI performed Estimated TIMI Risk Score Eval 6

7 Estimated TIMI Risk Score Eval Con t ARS Question 45 y/o Ptpresents to ED w/ complaint of nausea Father passed of age 52 BP 118/78, no meds No STE, Troponin I 3.2 Dx cath revealed 90% LCX PCI performed How will this PCI be classified for the AUC? U I A TIMI Risk Scores: Low Risk (TIMI Score 0-2) Intermediate Risk (TIMI Score 3-4) High Risk (TIMI Score 5-7) 7

8 Estimated TIMI Risk Score Eval Con t TIMI Score Impact A AUC SCORE: INDICATION:09 UA/NSTEMI and low-risk features (e.g., TIMI score <=2) for short-term risk of death or nonfatal MI Revascularization of the presumed culprit artery Appropriate Use Rating for Revacularization in ACS pts Sx onset 8

9 Appropriate Use Rating for Revacularization in ACS pts Con t Asymptomatic vs. recurring symptoms of MI Index Hospitalization vs. Post Index Hospitalization AUC Case Scenario Elective cath scheduled on 6/7/12, no CP Hxof CP controlled by Labetalol (BB) and Diltiazem(CCB) Previous admission 5/1/12 positive SPECT MPI w/ low risk Dxcathresults 100% Mid LCX chronic A PCI of the Mid LCX ARS Question #3 How will this PCI be classified for the AUC? Appropriate Median Score 7-9 Uncertain Median Score 4-6 Inappropriate Median Score 1-3 9

10 AUC Evaluation con t Elective cath scheduled on 6/7/12, no CP Hxof CP controlled by Labetalol (BB) and Diltiazem(CCB) Previous admission 5/1/12 positive SPECT MPI w/ low risk ARS Question Elective cath scheduled on 6/7/12, no CP Hxof CP controlled by Labetalol (BB) and Diltiazem(CCB) Previous admission 5/1/12 positive SPECT MPI w/ low risk Dxcathresults 100% Mid LCX chronic A PCI of the Mid LCX How will this PCI be classified for the AUC? I U A AUC Evaluation Con t Non- ACS patient variables: Level of ischemia = CCS I-IV Minimal Medical Therapy vs. Maximal = Anti-Anginal Non-Invasive Testing Results Additional Factors: -Single Vessel vs. Multi-Vessel CAD -Segment Location (Prox LAD) -IVUS/FFR -Hxof CABG 10

11 Variable Impact A 1-2V CAD, no prox LAD AUC SCORE: 07 AUC SCORE: 02 AUC INDICATION: 15 Elective cathscheduled on 6/7/12, no CP Hxof chest pain, on Labetalol(BB) and Diltiazem(CCB) Previous admission 5/1/12 positive SPECT MPI w/ low risk Dxcathresults PCI of Mid LCX 100% & Mid Mid LADLCX chronic AUC Case Scenario Cath scheduled on 8/21/12 Stable Angina w/ slight limitation w/ normal activity No AA therapy Stress Echo revealed low risk of ischemia 8/20/12 Dxcathrevealed 80% ProxLAD, PCI performed ARS Question #4 How will this PCI be classified for the AUC? Appropriate Median Score 7-9 Uncertain Median Score 4-6 Inappropriate Median Score

12 AUC Evaluation Con t Patient scheduled for cath on 8/21/12 Stable Angina w/ slight limitation w/ normal activity No AA therapy Stress Echo revealed low risk of ischemia 8/20/12 Dxcathrevealed 80% ProxLAD, which received a PCI AUC Question Patient scheduled for cath on 8/21/12 Stable Angina w/ slight limitation w/ normal activity No AA therapy Stress Echo revealed low risk of ischemia 8/20/12 Dxcathrevealed 80% ProxLAD, which received a PCI How will this PCI be classified for the AUC? U I A Display on Executive Summary Median Score 4 to 6 Uncertain for specific indication may be acceptable may be reasonable More research and/or patient information needed 54.6% 54.6% 12

13 CCS Classification No Sx s, CCS I, II, III, IV A U I Most Common AUC Indications for ACS pts Appropriate Indications # 1 # 12 Uncertain Indications # 9 Inappropriate Indications #3 Most Common AUC Indications for Non-ACS pts Appropriate Indications # 18 # 20 Uncertain Indications # 15 # 20 Inappropriate Indications # 14 # 22 13

14 AUC Resources online: Society for Cardiovascular Angiography & Interventions ( Health Outcomes Sciences ( Cardiosource ( 14