ACCA: Appropriate use is physician's professional duty

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CHICAGO—It is a physician's professional duty to acknowledge and form appropriate use criteria in healthcare, said Manesh Patel, MD, director of cath lab research at the Duke University Medical Center in Durham, N.C., during a presentation March 22 at the annual American College of Cardiovascular Administrators (ACCA) meeting. Additionally, he said that the current system needs work, but there may not be one solution to fix it.

“We need to become more efficient,” Patel offered. He said that currently many guidelines outline appropriate use criteria (AUC) of various procedures like PCI, but a national imaging database to track imaging exams does not yet exist.

Because no such AUC exist in the imaging field, it remains difficult to track physicians' work. It is unlike PCI, a procedure that has been under much scrutiny in the past few years with stories of overuse and inappropriate use. However, Patel said that in the more than two million PCIs that have been performed, 70 percent of patients have a 50 percent blockage.

“That is good; that is pretty good,” he noted.

Patel discussed recent data that looked at appropriate, inappropriate and uncertain numbers of PCIs. He said that it was found that 96 percent of acute PCIs were deemed appropriate; for elective PCI, 11 to 12 percent were deemed inappropriate.

“We need to be more efficient ... especially if you are looking to see whether a patient has a blocked artery," he said. "This current system is broken.”

Patel added that the system has room for improvement. “I don't know what the best imaging test is. I don’t have a dog in the race,” he said. “I just want the system to get better.”

He said the current system needs improvement in terms of noninvasive testing’s role in the decision to perform PCI and confirm coronary artery disease. “Maybe the system is currently as good as we want it to be, but it seems that we need to do a better job,” Patel said. “It's not an efficient system.”  
For imaging, there is no hard data to keep track on the false/negative results. However, he said that a paper outlining AUC for diagnostic catheterization will be coming out shortly, and will include a one-page preprocedural checklist to guide clinicians to the best care.

In terms of AUC for coronary revascularization, there are several clinical variables that help to guide decision making for PCI and CABG. These include:

  • Symptom status;
  • Medical management of angina; and
  • Ischemic burden (if a stress test was performed);

“Patients with more symptoms, more anatomy and more ischemia need revascularization,” Patel said. “And for those with less symptoms and less ischemia, revascularization may not be best.”

AUC guidelines work to “blend evidence and clinical experience and are concordant with clinical practice guidelines,” Patel offered. However, he added that these are not a “cookbook” for medical practice and should not substitute sound clinical judgment.

Additionally, he said that physicians should “recognize some ambiguity is intrinsic to clinical decision making ,” and said that guidelines help clinicians determine what tests, like stress tests, are appropriate.

Patel also questioned what the Centers for Medicare & Medicaid Services (CMS) is using to determine whether procedures are deemed appropriate or inappropriate. Additionally, he said that noninvasive imaging tests may be the “crux of the problem,” because no real-time feedback exists.

Patel concluded that it is the professional responsibility of physicians to have a commitment to quality and acknowledge and understand appropriate use. “If we don’t do it, who is going to do it?”

Additionally, he said that the costs of imaging in medicine will not be sustainable and that the U.S. needs to do a better job “figuring out who needs which picture” and implement strategies to do so. Physicians must consider patient wants, radiation dose and costs, among other factors.

 “We have a professional role and responsibility around appropriateness,” Patel said. “We need to focus on practical work flow and advocacy.”

In the future, with the help of the EHR, physicians may be able to load in  patient information, noninvasive findings and symptom data that can be analyzed to improve AUC.