Self-regulation Through Appropriate Use

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 - SPECT Myocardial Perfusion
Use of SPECT Myocardial Perfusion Imaging has been scrutinized recently.
Source: Miriam Hospital, Providence, R.I.

In 2009, the American College of Cardiology (ACC), along with other societies, updated and expanded guidelines for appropriate use of cardiac nuclear imaging with a practical document designed to facilitate sound decision-making. The goal was to optimize patient care efficiently, and by doing so, say good riddance to regulatory entities such as radiology benefits managers. Two years later, the strategy seems to be working, at least on some fronts.

In the U.S., use and spending on SPECT Myocardial Perfusion Imaging (SPECT MPI) and other imaging services burgeoned after 2000. According to an analysis by the Government Accounting Office (GAO), Medicare spending on imaging services more than doubled between 2000 and 2006. The 2008 report called out independent cardiologists in particular, claiming that cardiologists racked up the largest share of in-office expenditures of all specialties—$3 billion of the total $14 billion spent in 2006. Proportionally, more cardiologists had skin in the game, with 43 cardiologists per 100 physicians billing for in-office imaging services in 2006, up from 24 per 100 physicians in 2000.

The report recommended that the Centers for Medicare & Medicaid Services (CMS) adopt a front-end approach, such as instituting the use of radiology benefits managers (RBMs). Its authors noted that some private health insurance companies already required prior authorization through RBMs as a way to manage utilization and costs.

Build it and they will comply?

Even before 2008, ACC advocated another approach: identifying and publishing guidelines on the appropriate use of SPECT MPI, and in the next iteration in 2009, other nuclear cardiology modalities. The first guidelines were merely rules and regulations, says Robert C. Hendel, MD, director of cardiac imaging and outpatient services at the University of Miami Miller School of Medicine in Florida, and chair of the 2009 guideline writing group.

Guidelines as a framework for determining what indications fit testing may help chip away at overutilization, but only if physicians know of and follow them. And that is a challenge.   

“Expecting busy physicians to read guidelines and appropriate use criteria [AUC] and incorporate them into practice, never happens,” says Brahmajee K. Nallamothu, MD, MPH, a cardiologist at the Center for Healthcare Outcomes and Policy at the University of Michigan in Ann Arbor. “You have to re-engineer how practices flow and how patients receive care to have an impact.”

While not comprehensive, the 2005 guidelines helped cardiologists identify gaps and strategies for future directions. In a pilot study, Hendel and colleagues used the SPECT MPI recommendations as a template to track appropriate use in clinical practice. The results, based on 5,928 patients enrolled at six clinical sites between 2008 and 2009, were consistent with other AUC assessments: 71 percent of cases were appropriate; 15 percent were uncertain and 14 percent were inappropriate (J Am Coll Cardiol 2010;55:156-162).The findings allowed the researchers to identify patterns of inappropriate use and target them for improvement.    

“If you eliminated just one inappropriate indication, you would drop volume by 6 percent,” Hendel says, referring to what they found was the most frequent inappropriate indication: detection of coronary artery disease in asymptomatic, low-risk patients. “However, more importantly, you would get rid of about half the inappropriate studies.”

Most Common ‘Inappropriate’ Indications - 67.18 Kb
Source: Robert C. Hendel, Multicenter Assessment of the Utilization of SPECT MPI Using the ACC Appropriateness Criteria Pilot Study

Feedback and focus

The pilot study also let researchers develop tracking tools and feedback mechanisms to educate physicians and possibly improve adherence. After analyzing its data and educating staff, one site reduced its inappropriate use rate from 22 percent to 13.3 percent.    

The 2009 guidelines were purposely formatted to be embedded into decision-support algorithms, Hendel says. Early adapters included Northern California Kaiser Permanente in Oakland, which integrated the guidelines into its EMR to help clinicians order tests efficiently and appropriately, says Ralph G. Brindis, MD, MPH, senior adviser for cardiovascular disease at Northern California Kaiser Permanente and chair of the 2005 guidelines writing committee.

“There is no way you can manage patterns of care unless you actually measure them,” Brindis says. “Data feedback looking at different