This post was authored by Pranav Puri, a first year undergraduate student at The University of Chicago.

Approximately 600,000 percutaneous coronary interventions (PCIs) are performed in the U.S. each year at a cost that exceeds $12 billion. In recent years, the emphasis of the national health care system has shifted towards providing higher quality care at lower costs, and payment models are shifting away from fee-for-service towards population-based health management and bundled payments. In an effort to assist both physicians and patients in choosing the best procedure for patient outcomes, the ACC developed appropriate use criteria (AUC) for coronary revascularization in 2009 and released a focused update in January 2012.

In February 2012, UnityPoint Trinity in Rock Island, IL initiated a process involving the education and participation of physicians and nurses towards the implementation of the ACC’s AUC. Since the economic impact of AUC has been of interest to me for quite some time (read my previous blog on my poster presentation at ACC.13 here), my colleagues and I put together a study to assess the long-term effects of implementation of AUC on volumes of both interventions and diagnostics. We also studied the distribution of acute vs. elective interventions, and aimed to quantify the economic impact of implementation of the AUC.

Volumes of both diagnostics and interventions were measured in twelve month intervals for two years following the implementation of the AUC and compared to volumes in corresponding twelve month intervals in the two years preceding implementation. We found that implementation of the AUC had a significant impact on lowering volumes of both interventions and diagnostics. The volume of interventions decreased by 17 percent from 2011 to 2012, one year after implementation, and decreased by a further 17 percent from 2012 to 2013.

We determined that the consistent and continuous decline in volume was a result of the cumulative effects of the AUC process implemented at UnityPoint Trinity. The AUC process begins in the outpatient clinical setting where physicians fill out an initial AUC form that details the severity of patient symptoms, the intensity of medical therapy and stress test results. Documentation of this information nudged physicians towards making more rational and informed decisions about ordering cardiac catheterizations. We believe the decrease in the volume of diagnostics also influenced the volume of interventions. Similarly, physicians fill out an AUC form post-intervention and all AUC forms are peer reviewed on a monthly basis, which in turn influenced physician behavior and also contributed to lower volumes of PCI.

The further 17 percent decrease in volume of PCI from 2012 to 2013 suggests that lower volumes were not merely a knee-jerk reaction but rather that implementation of the AUC continued to influence physician practice patterns over the two year time period we studied. The ratio of acute to elective interventions increased from 42 percent to 49 percent. As a compounded result of lower volumes and lower average reimbursement from Medicare and third party payers, total hospital reimbursement decreased by 36 percent two years after implementation of the AUC. If a similar AUC process were to be implemented on a national level, we calculated a cost savings of more than $2.3 billion could be achieved.

We concluded that implementation of a robust AUC process that begins in the outpatient clinical setting and culminates with the peer review of each intervention, played a significant role in influencing physician practice patterns and lowering volumes of diagnostics and interventions as well as raising the ratio of acute to elective interventions.

We recently presented these findings during at a moderated poster session at ACC.15, and our study was received with great interest and insightful questions. Joseph Ladapo, MD, PhD, from NYU raised an incisive question asking whether other factors that could have contributed to the observed decreases in volumes. His question elicited a discussion that emphasized the importance of studying the effects of AUC since it builds a platform that incorporates the findings of randomized clinical trials and the growing body of knowledge of how to best provide value-based care. Although we did not measure outcomes in this study, we found a decrease in the volume of “appropriate” interventions from the first year after implementation of the AUC to the second year.

Acknowledging the effects of the AUC on influencing physician behavior, Gregory Dehmer, MD, MACC, the moderator of our session, pointed to the decrease in the volume of “appropriate” interventions and raised the question of whether implementation of the AUC had overshot its intended results. Perhaps, implementation of the AUC was denying appropriate care to a certain segment of the population?

As payment models continue to shift towards population-based health management and bundled payments, the AUC will likely assume a greater role in guiding therapy; therefore, to more comprehensively understand the effects of the AUC, we must seek out answers to questions such as those raised by Dr. Ladapo and Dr. Dehmer.

Check out my interview below with the FITs on the GO. For additional video coverage, visit YouTube.com/ACCinTouch. For all of the news from ACC.15, visit ACC.org/ACC15.

https://youtu.be/LQWv1QSfjWw?list=PL88XQBBe-9rPtvMuoV_6h5glXKH3bFfMT

 

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