Lead investigator Robert C. Hendel, MD, a clinical cardiologist at Midwest Heart Specialists in Chicago, told Cardiovascular Business News that the growth and cost of cardiovascular imaging has placed renewed attention on it, especially in regards to proper and optimal test ordering. However, he added that the true nature of utilization is unknown.
He said that the scrutiny has led to suggestions that practices undertake "onerous" processes of pre-authorization through radiology benefit managers, as recommended in the current Obama budget. "The use of these radiology benefit managers (RBMs) is costing tens of thousands of dollars to the healthcare industry and shuttling money out of healthcare and into the hands of this new cottage business to regulate healthcare," Hendel noted. "This type of criteria is a more integrated approach to manage imaging in a responsible way."
The American College of Cardiology Foundation (ACCF), the American Society of Nuclear Cardiology and payor United Healthcare formed a collaboration in March 2008 to test the feasibility and effectiveness of a different approach--one that reduces inappropriate exams while ensuring that patients have access to the imaging studies they need.
The ACC has developed appropriate use criteria to guide clinicians and payors about what constitutes a reasonable test for a specific indication--the right test for the right patient at the right time, Hendel said. Physicians are stepping up and taking an active role in imaging utilization, identifying when an imaging test is not needed, and developing physician-centered tools to accomplish these goals.
The study focused on SPECT-MPI usage in real-world clinical practice--six sites of varying sizes and locations with ACCF appropriate use criteria serving as a guide. Staff members prospectively collected and entered point-of-service clinical data into an online database on all patients referred for SPECT-MPI. An algorithm automatically determined whether the study was appropriate for each patient according to the appropriate use criteria and tracked patterns of inappropriate imaging.
A total of 6,351 patients were involved in the study. The computer-based algorithm was able to determine test appropriateness in all but 6.6 percent of the patients. "Ultimately, as this becomes more widespread, we can really evaluate the geographic implications--both throughout the country and within rural versus. suburban areas," Hendel added.
Based on the appropriate use criteria, the researchers found that 13.4 percent of studies were performed for inappropriate indications, while 66 percent were appropriate and 13.9 percent were of uncertain appropriateness. The most common instance of inappropriate testing was in asymptomatic, low-risk patients, which accounted for 44.5 percent of all inappropriate SPECT-MPI tests. Such patients have no objective signs of heart disease and have few risk factors for heart disease.
"If we could markedly reduce testing in these types of low-risk patients, we could reduce imaging volume, radiation exposure, and unnecessary downstream tests and procedures by a large amount--but we'd be doing so in a careful and selective manner," Hendel said. "We want to preserve patient access to the procedures they need."
The study documented wide variation of inappropriate testing among the practices studied, with a five-fold difference between the best- and worst-performing sites. These findings indicate an opportunity for the profession to measure baseline performance and to identify and share best practices. The study also found that more inappropriate testing was referred by physicians from outside practices rather than from within the same practice where the imaging was performed (18 vs.12 percent), suggesting that self-referral was not necessarily driving inappropriate testing, as has been alleged.
With this approach, according to Hendel, appropriateness can be measured, test ordering can be evaluated, and physicians can be educated about how to improve their performance. In fact, one practice reduced inappropriate testing from 22 percent to 13 percent after practitioners were given feedback and education, and other practices in the pilot were able to maintain a consistently low rate of inappropriate use.
"Throughout the past year, we noticed that once a practice began to recognize its patterns, then those physicians immediately begin to correct any inappropriate use of image ordering," Hendel said. "We hope to give the physician a way to manage their imaging utilization, as an alternative to RBMs."
Based on their findings, he said that there is clearly room for education initiatives throughout cardiovascular practices, and more utilization of the appropriateness criteria should be undertaken.
Hendel concluded that while the Obama budget has predicted that RBMs can conserve $260 million over 10 years, "we believe that can be achieved in just a few years through this appropriate criteria. We are looking to redefine the system and we are moving very quickly to implement it in a widespread way." He added that payors are looking for alternatives to the "costly and time-consuming RBMs."