dr.harold_overviewofamericancollegeofcardiology_sjmc cardiovascular symposium

Brief Overview of the American College of Cardiology

John Gordon Harold, MD MACC, MACP, FESC, FAHA

President Elect American College of Cardiology

February 9, 2013

ACC Leadership 2013 President: Dr. William Zoghbi

President-Elect: Dr. John Gordon Harold

Vice President: Dr. Patrick O’Gara Immediate Past President:

Dr. David Holmes Chair BOG: Dr. Dipti Itchhaporia Treasurer: Dr. Michael Valentine

http://members.acc.org/caextranet/About/PublishingImages/Dr.John Harold Gordon.jpg

American College of Cardiology 64 Years of Quality and Education

1949-2013

Heart House, Washington D.C.

The American College of Cardiology

The Mission of the ACC

To Transform

Cardiovascular Care and Improve

Heart Health

Invitation to San Francisco

ACC.13

Choosing Wisely: Appropriate Use Criteria,

Maintenance of Quality, and Cost Effective Practice

St. Joseph's Medical Center Cardiac Symposium - February 9, 2013

Stockton Golf and Country Club in Stockton, California

Presenter Disclosure Information for John Gordon Harold, MD MACC, MACP, FESC, FAHA

Clinical Professor of Medicine David Geffen School of Medicine at UCLA

and Cedars-Sinai Heart Institute Los Angeles, California

No relationships to disclose

• Appropriate Use Criteria (AUC): The development of appropriateness criteria - including something of the history behind them and the practicalities of their development

• Choosing Wisely Campaign: Avoiding Avoidable Care: Choosing Wisely in Cardiovascular Medicine

Is This Appropriate?

1978 Portland, Oregon Art Campaign Mayor of Portland

Presenter

Presentation Notes

I’m going to start with a quiz. This is the Mayor of Portland, Oregon in a 1978 poster from the “Expose Yourself to Art” campaign. Is this Appropriate?

Is This Appropriate?

1978 Portland, Oregon Art Campaign

Presenter

Presentation Notes

We don’t have an audience response system but I would say not appropriate.

Is This Appropriate? Not really

Presenter

Presentation Notes

And what about this highway billboard from Texas? Is this appropriate? Was your stent unnecessary? Call 1-888-DR-LEGAL. I can guarantee that there is no doctor at the other end of that phone line.

1 .30 to 2 .97 (57) 1 .1 to < 1 .30 (47) 0.9 to < 1 .10 (83) 0 .75 to < 0 .90 (51) 0 .35 to < 0 .75 (68) Not Populated

But is this Appropriate? Variation in rates of PCI - USA

Source: Dartmouth Atlas

Presenter

Presentation Notes

On the other hand, is this appropriate? This map from the Dartmouth Atlas shows marked variation in rates of PCI across the United States in the Medicare population per 1,000 Medicare beneficiaries. There is a 10 fold variation between the highest hospital referral region compared to the lowest referral region.

Variation in Rate of Inappropriate PCI Procedures in Non-Acute Indications

Chan P el al. JAMA 2011; 306:53

JULY 6, 2011

Heart Treatment Overused Study Finds Doctors Often Too Quick to Try Costly Procedures to Clear Arteries

Or This Appropriate?

Feds Probe HCA for Unnecessary Stenting By Chris Kaiser, Cardiology Editor, MedPage Today Published: August 07, 2012 A Florida nurse's complaint has led to a federal probe of potentially unnecessary cardiac procedures at HCA Holdings, the largest for-profit hospital chain in the U.S., according to news reports. At Lawnwood Regional Medical Center in Fort Pierce, Florida, for example, about 1,200 cardiac catheterizations were deemed to be unnecessary, according to a report in the New York Times.

Presenter

Presentation Notes

Or is this appropriate? Multiple headlines appearing in the lay press regarding overutilization of heart procedures including recent revelations from Hospital Corporation of American regarding facilities in Florida that are under investigation by the Federal government for alleged inappropriate deployment of coronary stents.

Explosion in Cardiovascular

Technology

Geographic Variation in the United States -Utilization of Noninvasive Diagnostic Imaging: Medicare Data, 1998–2007

Presenter

Presentation Notes

The variation noted on the Dartmouth Atlas is reproducible to almost any expensive cardiovascular procedure performed in the United States. This slide illustrates geographic variation and increased utilization of noninvasive diagnostic imaging in Medicare beneficiaries from 1998 through 2007. The color graphic illustrates the marked and substantial variation in the use of expensive cardiovascular procedures across the United States. The dark areas refer to high utilization and the light areas to low utilization.

Growth in Advanced Imaging CT, MR, and PET

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180 CT MR PET All Modalities

Cardiology Overall

Source: http://oig.hhs.gov/oei/reports/oei-01-06-00260.pdf.,

$0

$200,000,000

$400,000,000

$600,000,000

$800,000,000

$1,000,000,000

$1,200,000,000

$1,400,000,000

1998 2000 2002 2004 2006 2008 2010

MPS

Echo

ETT

Cath

Medicare Physician Payments for SPECT , Echo, Cardiac Cath, and ETT

www.cms.gov/DataCompendium/. Leslee S, Marwick T, Zoghbi W et al. JACC Img 2010

8.1% 8.5% 8.5% 8.7% 9.0% 9.1% 9.4% 9.9% 10.4% 10.5% 10.5% 10.7% 11.1% 11.2%

16.0%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

As P

erce

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GD

P Total Health Care Expenditure as a

Share of Gross Domestic Product (GDP) United States and Selected Countries, 2008

Australia 8.5% United States

16 %

Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.

Presenter

Presentation Notes

The United States is spending 16% of the gross domestic product on health care.

2013 >$10 Trillion

US Deficit

Presenter

Presentation Notes

We all know in the background of this variation that the current cost of healthcare is not sustainable.

Avoidable Care and Waste- Contributing Factors • Abundance of imaging & other technologies

(accuracy, detailed anatomy & physiology)

• Complex disease- comorbidities

• Greater patient awareness, demand for latest technology

• Fragmentation of care (repeat testing)

• Defensive medicine

• Demise of the physical examination (Generalist and Specialist)

• Fee for service model (incentive for overutilization)

• Futility & end of life issues

Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil . JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

Waste in US Health Care

Presenter

Presentation Notes

The “wedges” model for US health care follows the approach based on the model by Pacala and Socolow. The solid black “business as usual” line depicts a current projection of health care spending, which is estimated to grow faster than the gross domestic product (GDP), increasing the percentage of GDP spent on health care; the dashed line depicts a more sustainable level of health care spending growth that matches GDP growth, fixing the percentage of GDP spent on health care at 2011 levels. Between these lines lies the “stabilization triangle”—the reduction in national health care expenditures needed to close the gap. The 6 colored regions filling the triangle show one possible set of spending reduction targets; each region represents health care expenditures as a percentage of GDP that could be eliminated by reduction of spending in that waste category over time.

Presenter

Presentation Notes

Healthcare Reform in the United States is trying to constrain the rise in healthcare costs. Our Supreme Court recently upheld the affordable care act and we are transitioning from a volume-driven healthcare system to a value-driven healthcare system. The question that remains is how do we delivery high-quality, high-value-based care to our patients?

Unintended Variation and Waste in Healthcare

• Dr. Donald Berwick:

“We basically have two economic health care options- We can cut care… Or we can improve care.”

Presenter

Presentation Notes

Dr. Donald Berwick, the former United States Administrator of the Centers for Medicare and Medicaid Services has stated that “unintended variation is stealing health care blind.” We basically have two economic health care options: we can cut care; or we can improve care.

The National Strategy for Quality Improvement in Health Care’s

TRIPLE AIM

Better care 1

2

3

Healthy people/communities

Affordable care To preserve our specialty’s autonomy the ACC needs to provide direction and leadership with Guidelines, Performance Measures and Appropriate Use Criteria to achieve the “Triple Aim” in Cardiovascular Care.

The Appropriateness Imperative 2013 - Challenges for the Profession

• Changes in cardiovascular practice and health care reform in the United States and abroad

• Demand for measurement of quality • Demand for public reporting and transparency • Demand for assuring responsible diffusion of

cardiovascular innovation • Demand for appropriate use

Presenter

Presentation Notes

These challenges include: Changes in cardiovascular practice and health care reform in the United States and abroad Demand for measurement of quality Demand for public reporting and transparency Demand for assuring responsible diffusion of cardiovascular innovation Demand for appropriate use

Professionalism

Presenter

Presentation Notes

The Privilege of Self-Regulation in the United States requires professionalism. Inherent in the doctor-patient relationship is the desire for physicians to use available knowledge and judgment to provide the best possible care to their patients. In return, physicians hope to earn the trust and respect of their patients and community.

Why Appropriate Use Criteria?

Professional Responsibility

Commitment to

Quality

Components of quality…include appropriateness of case selection…

A quality program performs appropriately selected procedures…

- 2005 ACC/AHA/SCAI PCI Guidelines

We can do it better than anyone else

Presenter

Presentation Notes

The ACC held a summit to receive feedback on the AUC process and how it might be improved. This information was used to refine the methodology, including introducing early review of proposed clinical scenarios, larger expert panels, more comprehensive lists of clinical scenarios and ongoing coordination with clinical guidelines and other ACC Policy documents.

Appropriate Use Criteria (AUC) History (2004-2005)

• RAND/UCLA Appropriateness Criteria (1990’s)

• ACC’s Medical Directors’ Institute.

• ACC State Chapter requests for ACC National action based on Payer challenges and Redding, California PCI/CABG reviews.

• ACC Board of Governors encouraged.

development of appropriate use criteria.

• American College of Radiology and payers defining imaging growth and cost.

Presenter

Presentation Notes

More than a decade ago, usage statistics for diagnostic imaging showed it to be the fastest area of growth among all medical services covered by Medicare. At the same time, health plans in California were starting to review and question PCI and Coronary Bypass cases based on the "RAND/UCLA Appropriateness Method" which was developed in the 1980s. The rationale behind the method is that randomized clinical trials — the "gold standard" for evidence-based medicine — are generally either not available or cannot provide evidence at a level of detail sufficient to apply to the wide range of patients seen in everyday clinical practice. Although robust scientific evidence about the benefits of many procedures is lacking, physicians must nonetheless make decisions every day about when to use them. Consequently, a method was developed that combined the best available scientific evidence with the collective judgment of experts to yield a statement regarding the appropriateness of performing a procedure at the level of patient-specific symptoms, medical history, and test results.

ACC Board of Governors • Elected Governors – All 50 United States,

Territories, Military, Veterans Administration, Public Health, Canada and Mexico.

• Voice of the collective ACC membership.

• Diverse specialties/demographics.

• Majority are in private practice.

• Educates members on ACC initiatives.

Presenter

Presentation Notes

Participants in the ACC’s Medical Directors’ Institute at the time, as well as leaders from the ACC’s Board of Governors, saw these events as both a challenge and opportunity to look at both over- and underuse of procedures. Upon approval by the ACC Board of Trustees, the ACC created an AUC Working Group tasked with developing a methodology for evaluating the appropriateness of cardiovascular imaging. The group published its proposed methodology and soon after, in October 2005 released the first AUC document for Single Photon Emission Computed Tomography myocardial Perfusion Imaging (SPECT MPI)

ACC Appropriate Use Criteria Goals • The College will partner with clinicians, health plans,

payers and policymakers for rational/fair use and reimbursement for heart disease

• Blend evidence-base and clinical experience data, congruent with clinical practice guidelines

• Recognize that some ambiguity is intrinsic to clinical decision making

• AUC is not a substitute for sound clinical judgment or patient preference

• Steward equitably and efficiently limited United States health care resources

Presenter

Presentation Notes

Partner with clinicians, health plans, payers and policymakers for rational/fair use and reimbursement for heart disease Blend evidence-base and clinical experience data, congruent with clinical practice guidelines Recognize that some ambiguity is intrinsic to clinical decision making AUC is not a substitute for sound clinical judgment or patient preference Steward equitably and efficiently limited United States health care resources

Definition of Appropriate Use • An appropriate diagnostic or therapeutic procedure is one in

which the expected clinical benefit exceeds the risks of the procedure by a sufficiently wide margin such that the procedure is generally considered acceptable or reasonable care.

• For diagnostic imaging procedures, benefits include- incremental information which when combined with clinical judgment - augment efficient patient care, and the expected negative consequences (risks include the potential hazard of missed diagnoses, radiation, contrast, and/or unnecessary downstream procedures.

• For therapeutic procedures such as revascularization or ICD/CRT, the benefits include survival or health outcomes (such as improved symptoms, functional status, and/or quality of life) weighed against the risks of the procedure and subsequent related care.

What are Appropriateness Criteria? • Appropriate Use Criteria (AUC) define “what to

do”, “when to do”, and “how often to do” in the context of local care environments combined with patient and family preferences and values

• Address misuse, overuse and underuse

• Connected to guideline content

• Imply a level of detail and complexity that extends beyond the current recommendations

Presenter

Presentation Notes

AUC are intended to define “when to do” and “how often to do” a given procedure in the context of scientific evidence, the health care environment, the patient’s profile and a physicians judgment. While the criteria can help inform individual patient care decisions, they are best used to evaluate patterns of care by physicians over time. All of the criteria are developed by panels of clinical experts from the ACC Foundation and its partner organizations based on evidence and, when necessary, expert opinion.

AUC - “The Preface” 1. AUC blends evidence-base and clinical experience and is

concordant with Clinical Practice Guidelines

2. We recognize that some ambiguity is intrinsic to clinical decision making and that AUC is not a substitute for sound clinical judgment nor patient preference

3. Where practice patterns of individuals, groups or hospitals routinely conflict with AUC ratings, further evaluation and education, with tracking and feedback, should be considered

4. These terms were originally adopted from the RAND criteria and chosen after review and debate of various approaches for examining use of technology across various clinical populations.

Presenter

Presentation Notes

AUC blends evidence-base and clinical experience and is concordant with Clinical Practice Guidelines. We recognize that some ambiguity is intrinsic to clinical decision making and that AUC is not a substitute for sound clinical judgment nor patient preference. Where practice patterns of individuals, groups or hospitals routinely conflict with AUC ratings, further evaluation and education, with tracking and feedback, should be considered.

RAND/UCLA AUC Methodology Based on Modified Delphi Process

Presenter

Presentation Notes

The RAND Method with the Modified Delphi Process is used in the development of the AUC documents. Literature review and synthesis of the evidence is compiled against the specific list of indications and definitions. Appropriateness is determined by an expert panel that rates the indications in two rounds. The first round is done individually with no interactions. The second round is conducted in a face to face meeting where the panel members interact, discuss and explore their individual scoring.

APPROPRIATE USE CRITERIA Appropriate Use of Cardiovascular Technology: 2012

Appropriate Use Criteria Methodology Update A Report of the American College of Cardiology Foundation

Appropriate Use Criteria Task Force • Robert C. Hendel, MD,

FACC, FAHA, FASNC

• Manesh R. Patel, MD, FACC

• Joseph M. Allen, MA

• James K. Min, MD, FACC

• Leslee J. Shaw, PhD, FACC, FASNC, FAHA

• Michael J. Wolk, MD, MACC

• Pamela S. Douglas, MD, MACC, FAHA, FASE

• Raymond F. Stainback, MD, FACC, FASE

• Christopher M. Kramer, MD, FACC, FAHA

• Steven R. Bailey, MD, FACC, FSCAI, FAHA

• John U. Doherty, MD, FACC, FAHA

• Ralph G. Brindis, MD, MPH, MACC, FSCAI, ex officio

Appropriateness Definitions • Appropriate: generally acceptable and are a

reasonable approach for the indication.

• May be Appropriate Care (Uncertain): may be a reasonable approach for the indication. Does not mean Inappropriate and should be reimbursable.

• Rarely Appropriate Care (Inappropriate): is not generally a reasonable approach for the indication. - Does not mean fraud.

Presenter

Presentation Notes

The panels assess the benefits and risks of a procedure for different indications or patient scenarios and then determine whether the indication is appropriate, uncertain, or inappropriate. It is important to note that AUC ratings often contain more detailed scenarios than the recommendations covered in practice guidelines and thus subtle differences are possible. The criteria are also based on current understandings of technical capabilities and potential patient benefits of the procedures examined, and future evidence development require these ratings to be updated on a regular basis.

Median Score 7 to 9: Appropriate Care • An appropriate option for management

of this patient population due to benefits generally outweighing risks; effective option for individual care plans although not always necessary depending on physician judgment and patient specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication).

Median Score 4 to 6: May Be Appropriate Care

• At times an appropriate option for management of this patient population due to variable evidence or agreement regarding the benefits risks ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient based on additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).

Median Score 1 to 3: Rarely Appropriate Care

• Rarely an appropriate option for management of this patient population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).

Guidelines, Performance Measures & AUC: How Do They Differ?

• Guidelines: Synthesize evidence and recommend range of generally acceptable approaches for the diagnosis, management or prevention of conditions/diseases.

• Performance Measures: Specific clinical measures indicative of high-quality, evidence-based care

• AUC: Define the “when to do” and “how often to do” a given procedure in the context of scientific evidence – incorporates cost factors as well

Presenter

Presentation Notes

Guidelines: Synthesize evidence and recommend range of generally acceptable approaches for the diagnosis, management or prevention of conditions/diseases. Performance Measures: Specific clinical measures indicative of high-quality, evidence-based care AUC: Define the “when to do” and “how often to do” a given procedure in the context of scientific evidence – incorporates cost factors as well

Science tells us what we can do;

Guidelines what we should do;

Registries what we are actually doing.

Presenter

Presentation Notes

Science tells us what we can do;�Guidelines what we should do; Registries what we are actually doing

Translating Evidence Into High-Value Care

Antman, Circulation 2009:119:1180-1185. Antman, Circulation 2009:119:1180-1185.

Presenter

Presentation Notes

We have heard a lot about guidelines and there is no doubt that guidelines are critically important to figuring out this issue of how we will deliver high-quality care. Clinical practice guidelines help to translate evidence into high-value care. There is not a lot a focus on cost in the guidelines. The American College of Cardiology and American Heart Association have developed documents to supplement the guidelines. These include the Performance Measures and Appropriate Use Criteria. These documents make recommendations regarding the use of effective therapies to decrease use of inappropriate, unnecessary and potentially harmful therapies.

• SPECT-MPI • CCT/MRI • TTE/TEE • Stress Echocardiography • Coronary Revascularization:

PCI/CABG • SPECT-MPI Update • Diagnostic Cath • Peripheral Vascular Disease • Pacemaker/ICD (2013) • Multimodality (2013)

Appropriate Use Criteria (AUC)

J Am Coll Cardiol 2009; 53;530-553 Available at http://www.acc.org

"An effort to insert clinical rationality…"

AUC For Coronary Revascularization

Presenter

Presentation Notes

AUC documents prepared in cooperation with our partners in the House of Cardiology are an attempt to insert clinical rationality into decision making. This was one of the first AUC documents released.

AUC Account for an Array of Scenarios Revascularization Appropriateness

Non-invasive testing

Symptoms/Rx

Burden of disease

Presenter

Presentation Notes

AUC account for an array of clinical scenarios as highlighted in this example from the revascularization recommendations. Parameters include the burden of disease, symptoms and results of noninvasive testing.

Some Variation May be Warranted Defining Measures of Appropriateness

AUC Task Force!!

AUC: Implementation and Evaluation New Technology

• Migration towards point-of-order

• Embedded clinical decision support

• Tracking/data registry

• Reporting/feedback

Need to Engage Physicians beyond Cardiology…

AUC Conclusions • Winston Churchill one said: “The farther backward you

can look, the farther forward you can see.”

• Appropriate Use Criteria (AUC) were developed to review patterns of care and serve as a framework for assessing appropriateness of care. The vast majority of cardiologists are caring doctors who work hard to stay informed and make the best decisions for their patients.

• Even with established criteria, treatment decisions are complex and involve patient preferences and individual circumstances. The best decisions come from an informed doctor, an informed patient and an open dialogue.

Presenter

Presentation Notes

Winston Churchill one said: “The farther backward you can look, the farther forward you can see.” Appropriate Use Criteria were developed to review patterns of care and serve as a framework for assessing appropriateness of care. The vast majority of cardiologists are caring doctors who work hard to stay informed and make the best decisions for their patients. Even with established criteria, treatment decisions are complex and involve patient preferences and individual circumstances. The best decisions come from an informed doctor, an informed patient and an open dialogue.

Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. Shared decision making…

Medicine's Ethical Responsibility for Health Care Reform — The Top Five List

“A Top 5 list also has the advantage that if we

restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost-cutting purposes.”

Howard Brody, MD, PhD

New England Journal of Medicine

Components of the Choosing Wisely Campaign

• Messengers and Collaborators 34 specialty societies and Consumer Reports—

and growing • Communicate Messages Specialty societies, Consumer Reports, consumer

organizations and ABIM Foundation • Activate Concrete action around unnecessary tests and

procedures

Choosing Wisely Partners Societies Developing Lists • American Academy of Hospice and Palliative

Medicine • American Academy of Neurology • American Academy of Ophthalmology • American Academy of Orthopaedic Surgeons • American Academy of Otolaryngology-Head and

Neck Surgery • American Academy of Pediatrics • American College of Chest Physicians • American College of Obstetricians and

Gynecologists • American College of Rheumatology • American College of Surgeons • American Geriatrics Society • American Headache Society • AMDA • American Society for Clinical Pathology • American Society of Echocardiography • American Society of Hematology • American Society for Radiation Oncology • American Urological Association • North American Spine Society • Society of Cardiovascular Computed Tomography • Society of General Internal Medicine • Society of Hospital Medicine • Society of Nuclear Medicine and Molecular Imaging • Society of Thoracic Surgeons • Society of Vascular Medicine

Societies Developed Lists • American Academy of Allergy Asthma &

Immunology • American Academy of Family Physicians • American College of Cardiology • American College of Physicians • American College of Radiology • American Gastroenterological Association • American Society of Nephrology • American Society of Nuclear Cardiology • American Society of Clinical Oncology • National Physicians Alliance

Consumer Groups Through Partnership with Consumer Reports • AARP • Alliance Health Networks • Leapfrog Group • Midwest Business Group on Health • Minnesota Health Action Group • National Business Coalition on Health • National Business Group on Health • National Center for Farmworker Health • National Hospice and Palliative Care Organization • National Partnership for Women & Families • Pacific Business Group on Health • SEIU • Union Plus • Wikipedia

Presenter

Presentation Notes

Orange = particular CV societies

Choosing Wisely in the Media

http://abcnews.go.com/wn

http://www.magazinediscountcenter.com-sub.biz/index.php?file=prod_address&prod_id=822

http://www.consumerreports.org/cro/index.htm

http://www.forbes.com/

http://www.reuters.com/

http://www.pbs.org/newshour/

http://www.foxnews.com/

http://www.cnn.com/

http://www.afp.com/en

How ACC Created Its List • The American College of Cardiology asked its standing

Clinical Councils to recommend between three and five procedures that should not be performed or should be performed more rarely and only in specific circumstances.

• ACC staff took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that had the tightest inappropriate score in the AUCs and were Class III (risk > benefits) recommendations in the guidelines.

• The ACC’s Advocacy Steering Committee and Clinical Quality Committee each then reviewed the five items before sending it to the ACC Executive Committee for final review and approval.

1. Don't perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

2. Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

3. Don't perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.

4. Don't perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

5. Don't perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

Choosing Wisely Campaign

Keys to Avoid Inappropriate Tests • Choosing Wisely® - Do not perform

testing/procedures in low risk patients who have no documented symptoms or ischemia

• Avoid follow-up testing without change in status, without sufficient time since the last test

• Deficit reduction act of 2005

• More awareness and emphasis on cost & utilization

• Radiology Benefit Mangers (RBMs)

• More data on the need for less serial studies

• Appropriateness use criteria by medical societies, particularly ACC & ACR

Health Affairs, 29:189, 2010

Medical Decision Making

Physician Choice

Patient Choice

Shared Decision Making

Presenter

Presentation Notes

The ACC held a summit to receive feedback on the AUC process and how it might be improved. This information was used to refine the methodology, including introducing early review of proposed clinical scenarios, larger expert panels, more comprehensive lists of clinical scenarios and ongoing coordination with clinical guidelines and other ACC Policy documents.

Nationwide Campaign to Improve Heart Health

• To encourage patient

involvement and understanding of CV disease

• Evolving to:

– support guideline-based CV care and prevention

– extend the patient-physician relationship

– Shared decision making tools

Cardiosmart.org

2013 - Stormy Waters for Cardiology The Gulf Stream (1899) Winslow Homer

Presenter

Presentation Notes

These are tumultuous times for healthcare in the United States and across the World as epitomized by Winslow Homers “The Gulf Stream.” The Appropriateness Imperative is of one of the many challenges the profession is facing.

John F. Kennedy in a 1959 campaign speech:

“When written in Chinese the word crisis is composed of two characters. One represents

danger, and the other represents opportunity”

Presenter

Presentation Notes

John Kennedy observed in a 1959 campaign speech that “When written in Chinese the word crisis is composed of two characters. One represents danger, and the other represents opportunity…” Physicians have the historical opportunity of autonomy in their practice and with that comes the responsibility and privilege of self-regulation.

The 2013 Heart Specialist: Quality, Accountability, Transparency & Cost

The Doctor: Sir Luke Fildes, 1887, The Tate Museum, London

Presenter

Presentation Notes

Given the privilege of professional self-regulation in the United States, the Heart Specialists will be expected to focus on quality, accountability, transparency and cost.

The Mission of the ACC

To Transform

Cardiovascular Care and Improve

Heart Health

Presenter

Presentation Notes

Dr. Michael Wolk wrote in a 2004 President’s Page in the Journal of the American College of Cardiology that, “some may not see the importance of the College’s efforts to address appropriateness. Some might argue that explicit guideline performance indicators can be divisive and prefer we not enter this arena. However, if we do not lead in this effort, others may set criteria that may not be wise either for us as physicians or for our patients.” Eight years later, I believe the same scenario rings true. Today, not only does data show a decrease in imaging growth, but the ACC is often credited by payers, members of the United States Congress and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care. We look forward to working with our sister societies in transforming cardiovascular care and improving heart health from a patient-centered perspective.

dr.harold_overviewofamericancollegeofcardiology_sjmc cardiovascular symposium

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