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.
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
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!