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

Implementing Critical Congenital Heart Disease Screening Policies

According to the Centers for Disease Control and Prevention, it has been estimated that at least 280 infants with unrecognized critical congenital heart defects (CCHD) are discharged each year from newborn nurseries in the U.S. Pulse oximetry newborn screening, a simple bedside test to determine the amount of oxygen in a newborn’s blood and the pulse rate, can identify some infants with a CCHD before they show any signs.

The ACC has long advocated for the universal coverage of CCHD screenings for newborns. Studies have shown that this approach to early detection of more subtle forms of congenital heart disease can prevent related complications and promote early diagnosis and treatment.

In September 2011, HHS Secretary Sebelius approved adding screening for CCHDs to the Recommended Uniform Screening Panel, which has been invaluable information as states pursue this policy. Members of the ACC’s Adult Congenital and Pediatric Cardiology Section including Gerard Martin, MD, FACC, worked with HHS to develop recommendations for the implementation of the screenings.

At the state level, there has been a push by several of ACC’s chapters working with other pediatric and cardiovascular societies to introduce policies for the newborn screenings.

Just last week Virginia Gov. Bob McDonnell originally vetoed a bill supporting legislation that would establish a public-private work group to develop a program for screening newborns for critical congenital cyanotic heart disease using pulse oximetry monitoring and providing appropriate early intervention services to infants identified as having the disease. But upon further review and discussions with key stakeholders led by ACC Staff including Delegate Patrick Hope, the ACC Virginia Chapter and others including Mended Little Hearts and AHA, McDonnell decided to implement an executive order that would put the congenital heart disease screening policy in place and officially signed the order today. This is a great example of how a strong grassroots push can be effective and instrumental.

To date Indiana, Maryland, New Jersey, Tennessee, and West Virginia have approved plans that will assure universal testing of newborns for congenital heart disease. The New Hampshire legislature recently passed a CCHD screening bill, which will be reviewed by an oversight committee prior to the Governor’s evaluation and signature, and the Connecticut Senate recently passed a bill to require CCHD screening. The health departments of Michigan, Ohio and Alabama are also currently crafting regulations to require the screening.

The ACC’s State Government Relations team is currently strategizing with stakeholders to advance the screening requirement in several other states. We’ve come a long way over the past few years as the implementation of policies for CCHD screening becomes more widespread.

A Victory at the State Level

It is both an honor and a privilege to be a member of the cardiovascular community. But there is a responsibility that comes with the designation. The ACC and its members are committed to quality cardiovascular care in an effort to do the right thing for our patients.

Over the past two years, the Maryland Chapter of the ACC under the leadership of Sam Goldberg, MD, FACC, past president of the chapter, and several others at the chapter and national level have been working to develop an oversight system for all state hospitals performing PCIs. (Read previous blog posts on the topic here and here). The bill was introduced over a year ago, and just this past week the Maryland Legislature passed the bill which for the first time requires a state agency to develop requirements for peer or independent review, consistent with the ACCF/AHA/SCAI Guidelines for PCI, of difficult or complicated cases and for randomly selected cases for Maryland hospitals.

In a statement issued by the Maryland Chapter, Marc Mugmon, MD, FACC, president of the Maryland chapter stated, “Peer review is a fundamental component of any comprehensive continuous quality improvement effort and will enhance patient safety by providing constructive, objective feedback to cardiologists in a collaborative environment. Independent, external review will be free of bias and politics, and by identifying individual operator strengths and weaknesses, it will help achieve the highest standard of performance. This process will complement robust internal programs and will rapidly identify and address potential deviations from accepted evidence-based guidelines for the use of stents.”

The Maryland Chapter, at the invitation of the Maryland Health Care Commission, will be an integral part of the regulatory process to implement regulations and ongoing performance measures as a member of the newly establish Clinical Advisory Group.

This is a great example of what we can accomplish at the state level though the hard work of our Board of Governor leaders. Earlier this year the Maryland Chapter was presented with the award for Advocacy at the Leadership Forum, and I am pleased to see all of their hard work and efforts have come to fruition. I hope their efforts can be a model for other states.

Gooo Team ACC!

Yesterday I officially handed over the responsibilities of the Chair of the Board of Governors (BOG) to Dipti Itchhaporia, MD, FACC. We also said goodbye and a big thank you to the chapter Governors whose term has ended and welcomed the Governors who will begin their three year term. I cannot express how grateful the ACC is to have such strong, dedicated leaders at the state level. Taking on a BOG position in addition to the daily responsibilities and demands of our jobs is not an easy task. I can tell you from experience it can be a challenging role at times, but in the end, the opportunity to make a difference for the College and the profession is well worth the struggles.

As the opportunities for the BOG as a whole to come together to share ideas for the future are limited to a few times a year, we also took the opportunity to discuss several important issues facing the field.  Our keynote address was Dr. Richard Anderson, CEO of The Doctors Company. Dr. Anderson explained the new ACC national medical professional liability insurance program with The Doctors Company (meeting attendees can learn more Monday, March 26 from 2-3:30 p.m. during a session titled “Issues That Have Caused Medical Professional Liability Claims: Are You at Risk?”) We all know medical liability is a huge issue at the state and national level so his presentation was helpful to put things into perspective.

John Shuck, MD, FACC, governor of Delaware gave an update on the FOCUS program in Delaware and the progress since it has been mandated by Blue Cross Blue Shield of Delaware earlier this year. In addition we heard from Andrew Freeman, MD, FACC, about the Walk with a Doc program.

Even more importantly we had our first-ever Town Hall Meeting with the Board of Trustees (BOT) where we discussed the future of the ACC’s Appropriate Use Criteria (AUC). Given the continued focus on reducing escalating health care costs, more and more attention is being given to appropriate use criteria (AUC) as a means of reducing variations in care and ensuring appropriate use of technologies and therapies. (Read a previous blog post from Dr. Ralph Brindis about the future of AUC here).

Team BOT/BOG engaged in a lively discussion on AUC methodology and what needs to be improved going forward. Individuals spoke about the role of payers; the burden of expectations from patients, referring physicians, and other specialties; and the need for increased data and patient education. Others advocated for AUC to become living documents in the future. These conversations hopefully will guide us as we continue to find ways to help cv professionals understand and best utilize AUC and respond to concerns that may arise.

Overall it was a productive meeting and a great way to start ACC.12!

The SMARTCare Project

Last month at Leadership Forum I was pleased to present the esteemed James T. Dove Quality Award to the Wisconsin Chapter. The award is named after former ACC President and Chair of the Board of Governors, who left to us the legacy and the challenge to always strive to continually improve our practices, environments, patient care, and profession, no matter the challenges.

The chapter, through the guidance of Tom Lewandowski, MD, FACC and other Wisconsin ACC Leadership, has truly been a champion of implementing the ACC’s quality tools to improve patient care in the state.  The chapter recently engaged on an ambitious quality improvement project to combine all of the ACC’s tools into a focused project to address documented clinical quality, resource use, and cost variation in the treatment of stable ischemic heart disease (SIHC) called SMARTCare.

Using ACC-developed tools like FOCUS and data from the registries, SMARTCare brings science to the bedside to create a more robust method for assessing quality, cost and outcomes for care delivery. The chapter has been working closely with ACC staff to develop this ongoing project which is a collaboration with integrated health care systems, statewide, multi-stakeholder collaborative groups, including business coalitions, measurement and data collaborative groups, and a payment reform partnership.

This groundbreaking project aims to change the face of cardiology nationwide and will be a model for other states to use in the future. The chapter continues to develop SMARTCare Delivery and has even combined efforts with the Florida Chapter to develop a joint Center for Medicare and Medicaid Innovation Center (CMMI) Innovation Grant proposal. This proposal results from an immense amount of work, dedication, and time on the part of many, many hard working professionals.  We learn of the results of the grant proposal within the month. Congratulations and good luck!

The Maryland Battle Continues

The topic of inappropriate use of stenting has been a hot topic this past year in several states including Maryland. As Immediate Past President Ralph Brindis, MD, MPH, MACC wrote in a previous blog entry, “To be perfectly clear, the ACC does not condone inappropriate use of coronary stenting, overuse or misuse of any cardiovascular technology or therapy. That said, what’s happening in Maryland is a prime example of how a negative situation can be turned into a positive opportunity to improve quality and appropriateness of care.”

Over the past year, the Maryland Chapter, along with the Society of Cardiovascular Angiography and Interventions (SCAI), have been advocating for oversight guidelines for cath labs performing percutaneous coronary intervention (PCI).

The Maryland Chapter has been diligently working to implement internal and external peer review, but as MedPage Today recently reported: “a Maryland plan to regulate stent procedures has elicited a push-back from local chapters of the American College of Cardiology and the Society of Cardiovascular Angiography and Interventions (SCAI).” The “public outcry over” allegations of over-stenting have “spurred a technical advisory group to the Maryland Health Commission to recommend giving the commission the authority to regulate stent procedures as well as continuing evaluation of hospitals with stent programs.” However, “both the Maryland Chapter of ACC and the Maryland SCAI chapter said a better plan would be a two-tiered system of checks that includes an internal review that meets specific standards and an external peer review as an auditing mechanism.”

Although the battle in Maryland continues, their gallant efforts have not gone unnoticed, and this past week at Leadership Forum BOG Chair-Elect Dipti Itchhaporia and I presented Sam Goldberg, MD, FACC, governor of the Maryland Chapter with the ACC Chapter award for Advocacy.

As the famous Robert Frost saying goes, “Two roads diverged in a wood, and I – I took the one less traveled by, and that has made all the difference.” I applaud the amazing efforts of the Maryland Chapter who is working to do something more effective to prevent inappropriate uses.