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Cardiac Imaging: Appropriateness Criteria


MONTREAL -- Quality assurance in cardiac imaging requires that the individual modalities are used appropriately. Appropriateness guidelines are being developed for both clinicians and payers.

MONTREAL, Sept. 14 -- Quality assurance in cardiac imaging requires that the individual modalities are used appropriately, and appropriateness guidelines are being developed for clinicians and payers.

Robert Hendel, M.D., of Midwest Heart Specialists in Fox River Grove, IL, discussed quality assurance during a symposium sponsored by Bristol-Myers Squibb Medical Imaging held in conjunction with the American Society of Nuclear Cardiology (ASNC) meeting.

Quality assurance, in the field of nuclear cardiology, "is not about pretty pictures," said Dr. Hendel. "It's about what the impact is for our patients."

It requires that imaging laboratories be well trained in performing the studies they conduct. Efforts to maintain quality in this area exist in the form of accreditation from agencies such the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL). Both the American College of Cardiology (ACC) and the ASNC mandate ICANL accreditation. Quality assurance also requires that clinicians who interpret imaging studies are also properly trained.

Certification from the Certification Board of Nuclear Cardiology (CBNC) is aimed at maintaining quality in that area. Regular reassessments in these areas are needed, said Dr. Hendel, to ensure that quality is maintained.

A trickier component of quality assurance is ensuring that the right test is performed on the right patient at the right time. "All of us are under a great deal of scrutiny with what is happening with a lot of expensive diagnostic testing," said Dr. Hendel. "We are being held accountable, and I'd like to suggest that that's not such a bad thing." Scrutiny can help foster quality.

Selection of appropriate imaging modality is steeped in controversy. Physicians have their own preferences regarding use of cardiac imaging tests, and there are wide geographic differences in utilization patterns.

According to Dr. Hendel, in any specific situation, there usually is no right or wrong answer as to what test to use. "We have no data almost on the outcome of medical imaging studies. If you do a study, does it result in a life saved? Guess what? The FDA is asking that question."

Government agencies and third-party payers are becoming frustrated because they are witnessing use of all kinds of expensive imaging tests in all kinds of patients in what to them appears to be a free-for-all. This is leading to efforts, such as pre-certification, to clamp down on imaging test use as a way to preserve vanishing healthcare dollars.

But are these the people who should exclusively be choosing when to use an individual test? Dr. Hendel thinks not. He believes that clinicians working in the field, the experts in nuclear imaging, should have a say.

In an effort to obtain some degree of agreement on the appropriateness of the various imaging modalities, the American College of Cardiology Foundation (ACCF) and ASNC has convened expert panels to develop appropriateness criteria for each test. Their goal is not only to provide rational guidance to clinicians when selecting a test, but also to provide government agencies and third-party payers with a template for deciding which tests to reimburse, avoiding the need for clinicians to "jump through hoops" to receive payment for practicing good medicine.

Dr. Hendel was a member of the panel responsible for the development of the single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) appropriateness criteria, which were published last year. The panel included clinicians, healthcare economists, payers, and imaging specialists. To develop the criteria, the panelists first developed a list of indications, based on an extensive literature review. They then individually ranked them in terms of appropriateness, discussed these rankings, re-ranked them, and finally processed the results.

Similar appropriateness criteria have already been published for cardiac computed tomography (CT) and magnetic resonance imaging (MRI), and criteria are in the works for percutaneous coronary intervention (PCI) and echocardiography. There are also plans to develop criteria that compare one modality with another.

According to Dr. Hendel, the currently available appropriateness criteria are being well received. Physicians like them because they only offer guidance, not hard and fast rules, so they can still make choices based on their own clinical judgment and experience. Payers like them because they offer a rational approach to deciding which procedures to reimburse and which to question.

Controversy remains, however. Some physicians do not believe that clinicians should participate in any way in government and payer efforts to limit reimbursement of imaging procedures. Also, some payers refuse to use the appropriateness guidelines, choosing instead to use their own criteria.

While this resistance can be frustrating, Dr. Hendel is confident that with education about the appropriateness criteria and what they are trying to achieve, support will grow from both parties. He said that cracking down on reimbursement of imaging studies is going to occur no matter what, so it is best that clinicians take a proactive stance and be involved in how critical economic decisions are made.

"If we don't do this, someone else will," he said. "And they might not be as friendly to what we do as imagers as what this process [of developing our own appropriateness criteria] might allow. We've already seen payers adopt other principles, and we've had to go to them and say, 'stop!'"

Dr. Hendel hopes that the appropriateness criteria will stem not only overuse of imaging studies but also underuse, which can be costly down the road if it leads to use of more expensive tests later on or an increase in the number of preventable coronary events.

He is eager to obtain feedback from physicians and payers about the current appropriateness criteria, so that future versions can offer improvements. "This is a dynamic process," he said.

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