In Memoriam: ACC Past President Borys Surawicz, MD, MACC

ACC Past President Borys Surawicz, MD, MACC, a pioneer in electrocardiography and a significant contributor to the cardiovascular academic community, has passed away.

Originally a native of Moscow, Russia, Surawicz trained in Europe from 1939 – 1949 before serving as a medical officer of public health in Holmestrand, Norway (1949 – 1950). One year later, he was named chief of medicine for the Bogenhausen Hospital in Munich, Germany. Continue reading

A Good Reminder Not to Lose Sight of Patient Value When Looking at Costs of Care

This post was authored by William A. Zoghbi, MD, MACC, past president of the ACC, in response to the New York Times article on echocardiography charges.

The New York Times this week ran a feature article in its “Health” section on the variations in charges associated with echocardiography (The Odd Math of Medical Tests: One Scan, Two Prices, Both High). In addition to raising concerns about charges, the piece suggested not only an increase in the use of echocardiography, but also inappropriate use of the technology by physicians.

Discussions about variations in cost are important across the health care spectrum – charges for all health services, not just echocardiography, vary significantly from one institution to another in the US. However, as Dr. David Wiener of the American Society of Echocardiography (ASE) noted in the article, it’s important that these discussions take into account the multiple factors responsible for the variation, including our decentralized health care system, state regulations and the need to subsidize poorly reimbursed services. Furthermore, the actual charges have little to do with actual payment for services by private or governmental payers, as charges have become an index of overall health care costs and inflation for each institution over the years, and do not mirror actual payments – a mere fraction. Unfortunately, the uninsured in the US are burdened with negotiating these high charges to a more acceptable and realistic level, highlighting the need for reform and transparency in prices of rendered services.   Continue reading

Reaction to Public Citizen’s Criticism of Cardiac Screening Programs

Public Citizen, a consumer advocacy group, called on 20 hospitals today to stop marketing health screening programs directly to the public, saying such screenings do “a great disservice to the community … and to public health more broadly.”

In letters sent directly to the hospitals sponsoring screenings by HealthFair, based in Winter Park, FL, Public Citizen called on the hospitals to stop “fearmongering — scaring healthy individuals about their future health.” The letters note that for “many people, false-positive test results from this screening lead to unfounded anxiety and additional unnecessary, risky, and costly diagnostic procedures and treatment interventions.” They also point out that false positives can also lead to overdiagnosis.

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Tackling Imaging Legislation in the Golden State

This post is authored by Norman E. Lepor, MD, FACC, governor-elect of the ACC’s California Chapter.

Legislation that was introduced recently in California has grave implications for how cardiovascular services are delivered not only in the Golden State, but also nationwide if similar sweeping prohibitions are copied by other states. Senate Bill 1215 (S.B. 1215) threatens in-office ancillary exceptions (IOASE) across the House of Medicine, including exceptions for advanced modality  (including PET, CT and MRI) and many other services performed outside cardiology. Continue reading

CV Imaging… in FOCUS

In the last 10 to 15 years, technological advances have completely changed the way we deliver patient care on a daily basis. For cardiology in particular, noninvasive imaging is now central to clinical practice and research, irrespective of the disease entity or the area of interest of the cardiologist. Despite its unquestionable benefits, and because of earlier trends of increased utilization, medical imaging has been an area of focus by policymakers at the state and national level, as well as private payers; attempting to control who can perform imaging tests and where, through administrative protocols or state and federal laws as a means of reducing health care costs.

In my newest President’s Page in the Journal of the American College of Cardiology, I take a closer look at the past, present and future of cardiovascular imaging.  In particular I focus on what I consider to be a new imperative for medical imaging in light of the trend towards a more value-driven health care system and the fact that technology will continue to improve, enhancing our ability to diagnose and treat patients earlier. Novel technologies need to show a positive effect in patient care and outcome since ultimately, our driving concern is to achieve the triple aim of quality care, reasonable cost, and the health of the population.

The ACC has developed several tools to address over- and under-use of procedures and technologies and is widely credited by payers, members of Congress, and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care.

Notably, appropriate use criteria (AUC) define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC can be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging tests, while reducing clinically less appropriate tests. By providing physicians with their imaging utilization, use of AUC also encourages the providers in shared responsibility for judicious use of imaging services and can effect appropriate change in behavior better than that observed with changing reimbursement.

Further, the College’s “Imaging in FOCUS” (FOCUS) tool, a self-directed, quality improvement software and interactive community was developed to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. It has proven successful in reducing overuse of imaging. Unlike Radiology Benefit Managers (RBMs) which have been criticized by health care providers for delaying or denying unnecessary administrative burdens, basing decisions on inconsistent rules and practices and lacking clinical guideline transparency, FOCUS is transparent, grounded in AUC, and provides opportunities, and in some cases, incentives, for improved AUC adherence.

Along the line of appropriate use, this past spring the ACC released a list of “Five things Physicians and Patients Should Question” as part of the Choosing Wisely campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care. Three of the five recommendations were imaging related:

  • Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
  • Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
  • Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.

As we continue to work towards implementing quality tools and efforts to address over- and under-use of procedures, I am proud of the College and its members for being at the forefront of this continuously developing field and working to make sure that patients reap the benefits of advances in imaging technology in a transparent, evidence-based manner.

A Positive Outlook for AUC

This post is authored by Joe Allen, director of Translating Research into Practice at the ACC.

We have come a long way over the past few years with the implementation of Appropriate Use Criteria (AUC) and recognizing the value it provides for patient and physician decision making. The College is often credited by our members, payers, members of Congress and other stakeholders for taking proactive efforts to identify care with minimal benefit and provide tools to guide more appropriate, cost-effective care.

There is a positive outlook for AUC, as accreditation agencies, MOC Part IV, and Physician Quality Reporting System (PQRS) participation in 2013 all offer incentives in many states for use of AUC that can enhance the value of these efforts in a direct way.

Originally, AUC moved the discussion away from self-referral and allowed us to focus on quality with legislators avoiding several efforts to remove the Stark exemption. Congress has approved a specific demonstration project on AUC now being implemented by Centers for Medicare and Medicaid Services (CMS). This bill allowed us to offer an alternative to various payment cuts and avoid movement toward radiology benefits managers (RBMs) for now by CMS.

Several payers have begun discussions with ACC about implementing an alternative to RBMs through a FOCUS decision support tool and Quality Improvement program. Maryland and several other states were able to use AUC as a part of discussions about how standards should be set for review of percutaneous coronary intervention use.  Several states had their own efforts begun to develop their own state based standard and dropped theirs to adopt the ACC AUC.

Some RBMs, although not 100 percent concordant, have changed their policies for approval to more closely align with ACC over time. Some plans also have aligned coverage policies with the AUC, including expanding coverage in some cases for computed tomographic angiography. AUC are being used by the ACC Wisconsin and Florida Chapters to engage payers and the business community in a dialogue about how to stabilize and reform payment using AUC measures and shared decision making.

While there are instances in which AUC have been linked to review, authorization, and other policies that misuse the AUC for individual case review, these policies often preceded the AUC or would have occurred anyhow using more arbitrary criteria. Proactive adoption of AUC tools, review of AUC registry data, engagement in quality improvement efforts like FOCUS, and patient outreach like the Choosing Wisely Campaign can help obviate the need for such third party review in the future. The Criteria are never a perfect match for every patient and thus they should be used to inform and not dictate care for individual patients. AUC are best used to engage patients and practices in discussions of appropriate use, as a mirror to understand patient case mix over time, and to benchmark patient populations against others.

AUC can and will evolve in the future in response to member concerns about cookbook medicine, barriers to care, and misuse of the AUC.  However, the items above are just a few of the many ways AUC have been used to empower physicians and patients and counter the desire for third party regulation of clinical practice.  By doing so, the profession demonstrates the value of various procedures while helping all stakeholders engage in a dialogue on the value of various procedures for different patient populations.

The ACC’s 2012 Legislative Conference is coming up on Sept. 9-11. Also don’t miss the Annual Scientific Session of the American Society of Nuclear Cardiology (ASNC) held Sept. 6-9 in Baltimore, which will cover the latest advances in nuclear cardiology and multimodality imaging. Click here to register.

The Future of AUC in the Imaging Community

This post was authored by Manuel D. Cerqueira, MD, FACC, chair of the ACC’s Imaging Council.

Over the past eight years the ACC has developed Appropriate Use Criteria (AUC) for several imaging modalities with the goal of helping physicians choose the right test for the right patient.  As explained in a previous blog post, at one point usage statistics for diagnostic imaging was shown to have the fastest growth among all medical services covered by Medicare. Although this statistic has since declined, there is still generally room for improvement.

The AUC were developed to review patterns of care and serve as a framework for assessing appropriateness of care. As the terms for AUC (appropriate, inappropriate and uncertain) continue to be misconstrued by the media and payers, it has become increasingly important to educate these audiences about the effectiveness of AUC and the associated quality improvement tools in improving cardiovascular patient care.

Over the past few years, the College has advocated for the use of AUC as an alternative to prior-authorization based on arbitrary criteria, RBMs or “slash-and-burn” payment cuts (a great example of these efforts is in Delaware, which you can read about in a previous blog post here).  As payer’s use of AUC to determine payment becomes more prevalent, we have seen a deeper, more trusting relationships develop between insurance companies and physicians. The imaging community must continue to be stewards of AUC in order to maintain this level of credibility.

In addition, through Imaging in FOCUS, the College’s web-based Performance Improvement Module (PIM) based on ACC-developed AUC, physicians can track their appropriateness rates for radionuclide imaging (read more about FOCUS in a blog post here). The Imaging Council fully supports the use of FOCUS as a quality improvement tool in physician practices, hospitals and health plans, and we have identified promoting a PIM for echocardiography as a top priority for 2012. We urge other physicians and payers to adopt this tool as it provides real-time AUC benefit/risk calculations for individual patients and allows physicians and other organizations to track AUC patterns and exceptions over time.

The Imaging Council and Membership Section of the ACC will continue to represent the cardiovascular imaging community and work with ACC leadership to promote collaboration on issues facing cardiovascular specialists using imaging technologies to provide optimal patient care.

While an eye remains on the cardiovascular imaging community, it is my hope that through use of the AUC and these quality improvement tools, we choose the right test for the right patient, ultimately reducing waste in the health care system and improving care.

This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

For more information about the Imaging Council and Membership Section of the ACC and how to get involved, visit www.cardiosource.org/Imaging.

New AUC for Peripheral Vascular Ultrasound and Physiological Testing

Today the first Appropriate Use Criteria (AUC) for peripheral vascular ultrasound and physiological testing was released. Developed by the ACCF in collaboration with 10 other professional societies, the criteria help clinicians maximize the appropriate use of certain noninvasive vascular tests when caring for patients with suspected or known non-coronary arterial disorders.

It is estimated that more than 20 million adults in the U.S. have some form of vascular disease. Since ultrasound and other noninvasive laboratory tests can be essential tools to help clinicians evaluate vascular blockages and disease, the AUC were created in order to ensure the effective use of these diagnostic imaging tools.

The new criteria focus on indications where ultrasound and physiological testing is frequently considered. Of the 159 indications rated, 117 were rated as appropriate, 84 were rated as uncertain, and 54 were rated as inappropriate.

In particular, arterial vascular testing was found to be “appropriate” in about half of the clinical situations evaluated.  For example, there was “significant consensus regarding the appropriateness of cerebrovascular duplex ultrasound for evaluation of the patient with signs or clinical symptoms of cerebrovascular disease with 7 of 8 clinical indications rated as appropriate and 1 clinical indication rated as uncertain.”

Overall, vascular studies were deemed appropriate when clinical signs and symptoms were the main reason for testing. For example, it is reasonable to order a lower extremity vascular study for a patient who reports calf pain upon walking that resolves with rest. Tests that were conducted in patients with existing atherosclerotic disease or to establish a “baseline” after a revascularization procedure were also considered appropriate based on ratings.

Of the indications rated as “uncertain,” the panel noted variations in practice and important gaps in the evidence that made it difficult to determine appropriateness.  For example, there was uncertainty regarding the use of cerebrovascular duplex for assessment of the asymptomatic patient with risk factors or comorbidities associated with carotid artery stenosis, with 6 of 7 indications receiving an uncertain score. According to the writing panel, clinical and cost-effectiveness studies on non-invasive vascular testing are needed in order to gain more clarity.

Notably, one in five uses of vascular testing were determined to be “inappropriate” meaning that, although doing the test does not cause harm, the information gleaned would not further inform clinical judgment.

This new document joins the growing list of clinical guidelines that currently includes AUC for echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, cardiac radionuclide imaging, coronary revascularization and diagnostic catheterization. The intent of AUC is to “avoid over- or underutilization, thereby promoting optimal healthcare delivery along with justifying healthcare expenditures and promoting the best outcomes for patients with minimal risk.”

Over the past month here on the ACC in Touch blog, we’ve featured a special series – “Back to the Basics” of AUC – to discuss what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

Read more about the new AUC document on CardioSource here. Also be sure to check out my interview with CardioSource Video News on the new AUC document below. I invite you to leave any comments or thoughts below.

Back to the Basics: FOCUS in Delaware

This post was authored by John Shuck, MD, FACC, governor of the Delaware Chapter of the ACC.

Over the past few years the issue of appropriate use and radiology benefit managers (RBMs) has been a “hot topic,” particularly in Delaware. Recently, the misuse of RBM’s in denying cardiac stress imaging within the state came to national attention.  A Delaware patient was denied a cardiac stress test by an RBM used by a major health plan in Delaware. The patient was ultimately admitted to the hospital emergently for a catheterization and a lifesaving CABG was performed.  This patient’s plight became well-publicized and sparked investigations by the U.S. Senate Commerce Committee and Delaware Insurance Commissioner as to why the test was denied.

Thanks to the efforts of many at the ACC national and state level, this past fall the Delaware Insurance Commissioner announced that the health plan will support use of the ACC’s FOCUS: Cardiovascular Imaging Strategies tool by Delaware cardiologists to make decisions about certain diagnostic imaging tests, as an alternative to RBMs. Unlike RBMs, the FOCUS tool engages providers in ongoing feedback reports and quality improvement activities. At the same time it reduces third-party costs to physicians and health plans (read more about FOCUS in a blog post here).

In January 2012 the FOCUS health plan product went live incorporating many of the same elements present in the FOCUS performance improvement module. Under the agreement, the health plan will pay for cardiologists in the state to use the online tool, which allows for consistent application of appropriate use criteria to determine when cardiovascular imaging tests are needed. Importantly, the program also provides feedback reports on the patterns of appropriate use to physician practices and health plans. FOCUS participants then use the reports to complete action plans and share best practices.

This model for managing medical costs by focusing on patient-centered decision making and quality care will hopefully be implemented by other insurers and within other states when it comes to ensuring appropriate use of medical imaging. I’m happy to see our efforts to implement this program in Delaware have not gone unnoticed as several other ACC chapters are currently in talks with health plans to implement this program at the state level.

For more information about Imaging in FOCUS, visit CardioSource.org/FOCUS. This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

Back to the Basics: Imaging in FOCUS

This post was authored by Bob Hendel, MD, FACC, chair of the Imaging in FOCUS work group.

Overuse has been a potential problem for some time with the fee-for-service model of care. As mentioned in last week’s history of Appropriate Use Criteria (AUC) post, more than a decade ago, usage statistics for diagnostic imaging showed imaging to have the fastest growth among all medical services covered by Medicare. Additionally, marked geographic variation in use patterns is present, further raising questions about the appropriateness of cardiac imaging in certain setting. This procedural growth has slowed in recent years, with a number of factors contributing to this decline.

In 2010, the ACC developed Imaging in FOCUS, a national quality improvement initiative designed to help cardiovascular professionals best use AUC and ultimately reduce inappropriate imaging. The FOCUS initiative is comprised of a voluntary community as well as a case review tool to provide appropriate use determinations for individual patients and allows physicians and other organizations to track AUC patterns and exceptions over time.

To date, Imaging in FOCUS is comprised of over 600 sites distributed throughout the country. Sites document their AUC patterns, goals, and action plans in a structured, three-part performance improvement module and utilize the FOCUS Community resources to help inform their work. The community is also working on best practices in implementing AUC. Many sites are imaging labs reviewing AUC patterns for quality improvement credit toward lab accreditation. ABIM maintenance of certification Part IV (quality improvement) credit is also available for participating physicians.

Since the FOCUS community’s start, the College has already documented significant improvements in appropriate use (as high as 50% reduction in inappropriate use). The College has also been working with ACC Chapters and insurance companies to widely adopt a new web-based tool powered by Medicalis as an alternative to third party radiology benefit managers that require prior authorization for procedures.  This tool provides a way for physicians and their staff to implement AUC at the point of care (web portal or EHR integration). This approach is currently in use in Delaware. It is built upon ACC core competencies and offers a performance-based, transparent and accountable solution to reduce inappropriate testing, not just indiscriminant volume reduction. This same product will be offered directly to practices and hospitals later this year for direct use in patient care on an ongoing basis and contract negotiations with individual payers.

We’ve come a long way over the past few years but our work is not yet done as we still are working to educate health plans and members of Congress about the benefits of AUC, as well as what the College is doing to put AUC directly in the hands of providers and ensure appropriate testing. Through these efforts and other programs, the College wishes to promote optimal patient care and resource-sensitive procedural utilization.

For more information on how to engage health plans or other stakeholders around these issues as well as more about ACC’s Imaging in FOCUS initiative, visit www.CardioSource.org/FOCUS.