This month’s post comes to us from Robert Hendel, M.D., F.A.C.C., chair of the Cardiac Radionuclide Imaging Writing Group, member of the Appropriate Use Criteria Task Force AND chair of the Evaluation and Implementation of Appropriate Use Criteria. As you can see, Dr. Hendel has quite the interest in improving quality. He also led the way in demonstrating the effectiveness of appropriate use criteria to reduce inappropriate testing when he released the results of a pilot with UnitedHealthCare on SPECT MPI.

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President Obama’s speech to the American Medical Association last week has been the topic of much discussion within the health care community. While outlining many components of his vision for health care reform, his emphasis on quality care resonated with me, largely due to the ACC’s continuing focus on this area. As the President stated, “…the bulk of our costs is the nature of our health care system itself – a system where we spend vast amounts of money on things that aren't making our people any healthier; a system that automatically equates more expensive care with better care.”

Unfortunately, cardiology was specifically mentioned in a less than flattering fashion, when he cited the recent JAMA publication that found only half of all cardiac guidelines are based on scientific evidence.

Improving Care through Clinical Documents
However, this conclusion is misleading with regards to the value of practice guidelines and the overall aim of providing the best care. Not every clinical scenario has robust literature support and in its absence, expert consensus opinion must fill the void to assist cardiologists in decision-making. The ACC, in conjunction with the American Heart Association and many subspecialty organizations, has been a leader in the medical world in developing documents to guide clinicians. Through practice guidelines, performance measures and appropriate use criteria, the College has been instrumental in improving cardiovascular care.

Beyond documents that define optimal, “must do” therapeutics, such as performance measures, clinicians need guidance in selecting the right test for the right patient at the right time. Since the inception of appropriate use criteria, which seek to define what test or procedure would be reasonable to perform for a given clinical situation, there has been a growing acceptance of this approach. The appropriate use criteria movement has been carefully followed by the Centers for Medicare and Medicaid Services (CMS) and private health plans, receiving almost universal praise.

Because of their basis on a strict, well-accepted methodology and that they are continually modified to provide contemporary application for resource utilization and reimbursement, appropriate use criteria have been recognized by national quality organizations. The most recent criteria, which are a revision of the radionuclide imaging criteria originally published in 2005, now have closed many of the gaps in the criteria’s application and are based largely on patient care flow diagrams. Other appropriate use criteria documents are now being revised and a multimodality approach to imaging criteria is underway in conjunction with the American College of Radiology.

Implementation, Evaluation
While creating these documents is very important, the ACC also is committed to the implementation and evaluation of appropriate use criteria, a critical component to actually affecting health care. In March, I presented the results of the multicenter pilot examination of the SPECT [Single Photon Emission Computed Tomography] Appropriate Use Criteria done in partnership with United HealthCare, which revealed the feasibility of applying the criteria to improve care. The pilot also was helpful in identifying areas of improvement in the use of SPECT.

CMS now has begun planning for a $10 million demonstration project testing appropriate use criteria and has involved ACC directly in the dialog. Furthermore, appropriateness is now a key focus of national medical quality organization, like the National Committee on Quality Assurance, AQA Alliance and others.

Physicians as Quality Drivers
We, as cardiologists, along with our representative organization, the ACC, must not lose momentum. We have to continue to drive the process from the physician perspective, with emphasis on quality and patient access. If we lose our focus, we risk having external forces, such as radiology benefits management companies, dictate the practice of cardiology. While the realigning of incentives to encourage quality is clearly needed, we must also do all we can right now to ensure that our patients receive the highest quality of cardiovascular care by using clinical documents to guide care choices.

- By Robert Hendel, M.D., F.A.C.C.

* Dr. Hendel's post is part of a monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!  

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