1. 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
2. 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
3. American College of Cardiology
64 Years of Quality and Education
1949-2013
Heart House, Washington D.C.
7. 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
8. 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
9. • 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
13. But is this Appropriate?
Variation in rates of PCI - USA
1.30to 2.97 (57)
1.1 to <1.30 (47)
0.9 to <1.10 (83)
0.75to <0.90 (51)
0.35to <0.75 (68)
Not Populated
Source: Dartmouth Atlas
14. Variation in Rate of Inappropriate PCI
Procedures in Non-Acute Indications
Chan P el al. JAMA 2011; 306:53
15. Or This Appropriate?
JULY 6, 2011
Heart Treatment Overused
Study Finds Doctors Often Too Quick to Try
Costly Procedures to Clear Arteries
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.
17. Geographic Variation in the United States -Utilization of
Noninvasive Diagnostic Imaging: Medicare Data, 1998–2007
18. Growth in Advanced Imaging
CT, MR, and PET
Cardiology Overall
CT MR PET CT MR PET All Modalities
1.4 180
160
1.2
Services per 1,000 Medicare Beneficiaries
140
1
120
0.8 100
0.6 80
60
0.4
40
0.2
20
0 0
Source: http://oig.hhs.gov/oei/reports/oei-01-06-00260.pdf.,
19. Medicare Physician Payments for
SPECT , Echo, Cardiac Cath, and ETT
$1,400,000,000
$1,200,000,000
$1,000,000,000
$800,000,000 MPS
Echo
$600,000,000 ETT
Cath
$400,000,000
$200,000,000
$0
1998 2000 2002 2004 2006 2008 2010
www.cms.gov/DataCompendium/.
Leslee S, Marwick T, Zoghbi W et al. JACC Img 2010
20. Total Health Care Expenditure as a
Share of Gross Domestic Product (GDP)
United States and Selected Countries, 2008
18%
16%
United States
Australia 8.5% 16 %
14%
12%
As Percentage of GDP
10%
8% 16.0%
6% 11.2%
10.5% 10.5% 10.7% 11.1%
9.9% 10.4%
9.0% 9.1% 9.4%
8.5% 8.5% 8.7%
4% 8.1%
2%
0%
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.
22. 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
23. Waste in US Health Care
Donald M. Berwick, MD, MPP; Andrew D.
Hackbarth, MPhil . JAMA. 2012;307(14):1513-
1516. doi:10.1001/jama.2012.362
24.
25. 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.”
26. The National Strategy for Quality
Improvement in Health Care’s
TRIPLE AIM
1 Better care
2 Healthy people/communities
3 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.
27. 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
29. Why Appropriate Use Criteria?
Commitment We can do it
Professional
to better than
Responsibility
Quality anyone else
Components of quality…include appropriateness of case selection…
A quality program performs appropriately selected procedures…
- 2005 ACC/AHA/SCAI PCI Guidelines
30. 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.
31. 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.
32. 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
33. 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.
34. 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
35. 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.
37. 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, • Raymond F. Stainback, MD,
FACC, FAHA, FASNC FACC, FASE
• Manesh R. Patel, MD, FACC • Christopher M. Kramer,
• Joseph M. Allen, MA MD, FACC, FAHA
• James K. Min, MD, FACC • Steven R. Bailey, MD, FACC,
• Leslee J. Shaw, PhD, FACC, FSCAI, FAHA
FASNC, FAHA • John U. Doherty, MD, FACC,
• Michael J. Wolk, MD, MACC FAHA
• Pamela S. Douglas, MD, • Ralph G. Brindis, MD, MPH,
MACC, FAHA, FASE MACC, FSCAI, ex officio
38. 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.
39. 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).
40. 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).
41. 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).
42. 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
43. Science tells us what we can do;
Guidelines what we should do;
Registries what we are actually doing.
44. Translating Evidence Into High-Value Care
Antman, Circulation 2009:119:1180-1185.
Antman, Circulation 2009:119:1180-1185.
46. AUC For Coronary Revascularization
"An effort to insert clinical rationality…"
J Am Coll Cardiol 2009; 53;530-553
Available at http://www.acc.org
47. AUC Account for an Array of Scenarios
Revascularization Appropriateness
Non-invasive testing
Symptoms/Rx
Burden of disease
48. Some Variation May be Warranted
Defining Measures of Appropriateness
AUC Task Force!!
49. AUC: Implementation and Evaluation
New Technology
• Migration towards point-of-order
• Embedded clinical decision support
Need to Engage Physicians
• Tracking/data registry
beyond Cardiology…
• Reporting/feedback
50. 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.
51. 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…
52. 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
53. 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
54. Choosing Wisely Partners
Societies Developed Lists Societies Developing Lists
• American Academy of Allergy Asthma & • American Academy of Hospice and Palliative
Immunology Medicine
• American Academy of Family Physicians • American Academy of Neurology
• American College of Cardiology
• American Academy of Ophthalmology
• American College of Physicians
• American Academy of Orthopaedic Surgeons
• American College of Radiology
• American Gastroenterological Association
• American Academy of Otolaryngology-Head and
Neck Surgery
• American Society of Nephrology
• American Academy of Pediatrics
• American Society of Nuclear Cardiology
• American Society of Clinical Oncology
• American College of Chest Physicians
• National Physicians Alliance • American College of Obstetricians and
Gynecologists
Consumer Groups • American College of Rheumatology
Through Partnership with Consumer Reports • American College of Surgeons
• AARP
• American Geriatrics Society
• Alliance Health Networks
• Leapfrog Group
• American Headache Society
• Midwest Business Group on Health • AMDA
• Minnesota Health Action Group • American Society for Clinical Pathology
• National Business Coalition on Health • American Society of Echocardiography
• National Business Group on Health • American Society of Hematology
• National Center for Farmworker Health • American Society for Radiation Oncology
• National Hospice and Palliative Care Organization • American Urological Association
• National Partnership for Women & Families • North American Spine Society
• Pacific Business Group on Health • Society of Cardiovascular Computed Tomography
• SEIU • Society of General Internal Medicine
• Union Plus • Society of Hospital Medicine
• Wikipedia • Society of Nuclear Medicine and Molecular Imaging
• Society of Thoracic Surgeons
• Society of Vascular Medicine
56. 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.
57. 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).
58.
59. 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
60. Health Affairs, 29:189, 2010
• 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
63. 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
64. 2013 - Stormy Waters for Cardiology
The Gulf Stream (1899) Winslow Homer
65. 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”
66. The 2013 Heart Specialist:
Quality, Accountability, Transparency & Cost
The Doctor: Sir Luke Fildes, 1887, The Tate Museum, London
67. The Mission
of the ACC
To Transform
Cardiovascular
Care and
Improve
Heart Health
