Workshops on Vascular Interventions: Are You Being Appropriate and Will You Be Paid?
One of the most talked about subjects at the SCAI 2013 meeting was the Appropriate Use Criteria (AUC). There are great economic and potential implications associated with the designations of appropriate or inappropriate for specific diagnostic procedures and treatments. Last year, SCAI with Kalon Ho launched an app that is used by interventional cardiologists to better determine AUC for various procedures diagnostic and otherwise.
Kenneth Rosenfield, MD, cardiologist and chairman at Massachusetts General Hospital, began the session by reviewing AUC scores for different specific indications. Focus was dedicated to peripheral vascular intervention (PVI) in contrast to coronary artery disease (CAD). PVI occupies a much wider space than CAD. As such it is exceptionally difficult to develop an AUC for PVI. In a series of case study-based question and polling sessions with on-site audience physicians, Dr Rosenfield made it evident that the choice of “appropriate,” “inappropriate,” or “uncertain” for a given treatment decision was frequently different for different individual physicians even when both physicians had expressed identical primary considerations. He pointed out that you could even have situations where all 6 criteria for quality care as defined by the Institute of Medicine may be met for a given circumstance, yet the procedure would still be judged as inappropriate. Most significantly Dr Rosenfield highlighted that insurance companies are now requesting AUC policies with the intent of using this information to develop their coverage schedules accordingly.
Next Ralph G. Brindis, MD, a cardiologist the University of California, San Francisco, presented a discussion entitled, “How Does One Measure Appropriateness?” Dr Brindis pointed out that the CARE registry part of the NCDR is now changing to a PVI registry. This is a positive development in his opinion. He commented on how the guidelines have almost become “shelfware” that is not as widely appreciated as it should be. Of particular note he has been surprised at the occasional complete lack of awareness of fellows and some physicians of the CathPCI metric that is offered to every hospital. Dr Brindis expressed that all of these people should be fully aware of this annual metric. It is an essential component to monitoring the quality of your care as compared to the rest of the country. The results offered by the NCDR are private and not shared with other institutions.
Two case studies were presented by Thomas T. Tsai, MD, a cardiologist with the University Denver in a talk entitled, “Case and Point: AUC Applied In Practice (2 Cases).” Dr Tsai illustrated through participatory polling with the physician audience that deciding whether to do a computer tomography angiogram (CTA) is by no means a majority consensus decision many times. Even if all of the potential pre-CTA factors are taken into consideration, there still remains the possibility that the CTA would reveal newly discovered concerns owing to its powerful image detail. In a patient with 1 block claudication that was not open to starting an exercise routine, the 93% of the physician audience would agree that PVI was an appropriate treatment. As it turns out, Dr Tsai had undertaken this direction of treatment and the patient no longer has any claudication problems 2 years after treatment.
The final presentation by Lloyd W. Klein, MD, cardiologist with the Rush University Medical Center in Chicago shared his experiences with coronary medicine and the AUC. He was critical of the policy that says that a minority of the AUC committee for a given procedure should be made up of those who specifically perform the procedure. For example 4 out of 17 were interventional cardiologists, where the remainder were surgeons or had other backgrounds. He does not see this as ideal for propelling the highest quality procedures into the appropriate category that they deserve. He pointed out how the fractional flow reserve metric is going to be recognized much more by the AUC in its evaluation of catheterization laboratories. In the end he covered several examples where he was dinged with the inappropriate use, but he still feels confident in the treatment decisions that he had made. He argued that the AUC is not always covering all of the possible parameters. One of his biggest concerns was the fact that for some elderly patients, the desired procedural outcome is not as much to merely extend life as much as it is increase the quality of life. This is a personal choice coming from the patient and it can have an important effect on the desired treatment.
On the whole the session was very pleasant and highly participatory in nature. Physicians appreciated both the strengths and limitations of the AUC approach to medicine.