Societies Release Appropriate Use Criteria for Diagnostic Catheterization

Of 166 identified possible clinical scenarios that may warrant diagnostic catheterization, nearly half are appropriate, a third are uncertain, and about a quarter are inappropriate, according to the first document to detail the appropriate use criteria for the invasive cardiac procedure.

Cardiovascular care accounts for a substantial portion of Medicare and overall health care burden in the United States, so "the movement towards developing appropriate use criteria is to help inform when it’s reasonable to a do a procedure for both patients and clinicians who are referring for the procedure, and then payers who are thinking about understanding patterns of use," said Dr. Manesh R. Patel, cochair of the report’s writing committee, and an assistant professor and director of Catheterization Laboratory Research Program at Duke University.

The report was released on May 9 by the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI), in collaboration with a group of professional societies (J. Am. Coll. Cardiol. 2012 May 29 [doi:10.1016/jacc.2012.03.003]).

The diagnostic catheterization appropriate use criteria follow those focusing on coronary revascularization, released in January (J. Am. Coll. Cardiol. 2012 Jan. 20 [doi:10.1016/jacc.2011.12.001]).

"Many will ask, Why do we need this now?," said Dr. Patel. "In part, because the reality is, without us leading the field and developing criteria for use, others will do that for us, and this is an opportunity for us to show our professional responsibility," he said.

Appropriate use criteria reports in general help reduce variations in practice and improve quality of care, said Dr. Christopher J. White, president of SCAI and professor of medicine and chairman of the dept. of cardiovascular diseases at Ochsner Clinic, New Orleans.

The documents, however, are much softer and broader than guidelines and should not be looked at as rules, said Dr. White, who was not involved in drafting the statement.

In detailed charts, the document gives scores of 1–9 to 166 indications for diagnostic catheterization procedures, which include left heart and right heart catheterization, ventriculography, and coronary angiography.

The statement recommends, in part, that diagnostic coronary catheterization is:

• Appropriate for patients with definite or suspected acute coronary syndromes; patients with planned vascular surgery; preoperative catheterization for coronary anatomy; and patients with symptomatic and severe valvular heart disease with discordant clinical and noninvasive imaging findings.

• Uncertain or inappropriate for asymptomatic and symptomatic coronary artery disease patients with low or intermediate pretest probability and patients without symptoms but with severe disease.

• Inappropriate for asymptomatic patients who have had prior noninvasive testing with low-risk findings and patients without symptoms with mild to moderate stenosis or concordant clinical and noninvasive findings.

"It is hoped that payers would use these criteria to ensure that their members receive necessary, beneficial, and cost-effective cardiovascular care, rather than for other purposes," according to the document. "It is expected that services performed for appropriate and/or uncertain indications will receive reimbursement," adding that services performed for inappropriate indications may require additional documents for payment due the unique nature of the patient circumstance. "This additional documentation should not be required for uncertain indications."

Dr. White said that they key message from appropriate use criteria documents is that "these are good for doctors, and they only become problems when they’re misinterpreted. ... This is a document for physicians to help them reduce variations in their practice," he said, adding, "We have to understand that underuse is as powerful as overuse."

In the document the panel has also developed a worksheet where referring physicians can check the reasons they want the procedure to be performed and the reasons the patient is being referred. "Our hope is eventually that we’ll have real-time tools that can help with decision support for physicians and patients when they’re making decisions not just about cardiac catheterization, but about other procedures and patient care," said Dr. Patel.

Dr. Patel had no relevant disclosures. Dr. White is on the editorial advisory board for Cardiology News.

Of 166 identified possible clinical scenarios that may warrant diagnostic catheterization, nearly half are appropriate, a third are uncertain, and about a quarter are inappropriate, according to the first document to detail the appropriate use criteria for the invasive cardiac procedure.

Cardiovascular care accounts for a substantial portion of Medicare and overall health care burden in the United States, so "the movement towards developing appropriate use criteria is to help inform when it’s reasonable to a do a procedure for both patients and clinicians who are referring for the procedure, and then payers who are thinking about understanding patterns of use," said Dr. Manesh R. Patel, cochair of the report’s writing committee, and an assistant professor and director of Catheterization Laboratory Research Program at Duke University.

The report was released on May 9 by the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI), in collaboration with a group of professional societies (J. Am. Coll. Cardiol. 2012 May 29 [doi:10.1016/jacc.2012.03.003]).

The diagnostic catheterization appropriate use criteria follow those focusing on coronary revascularization, released in January (J. Am. Coll. Cardiol. 2012 Jan. 20 [doi:10.1016/jacc.2011.12.001]).

"Many will ask, Why do we need this now?," said Dr. Patel. "In part, because the reality is, without us leading the field and developing criteria for use, others will do that for us, and this is an opportunity for us to show our professional responsibility," he said.

Appropriate use criteria reports in general help reduce variations in practice and improve quality of care, said Dr. Christopher J. White, president of SCAI and professor of medicine and chairman of the dept. of cardiovascular diseases at Ochsner Clinic, New Orleans.

The documents, however, are much softer and broader than guidelines and should not be looked at as rules, said Dr. White, who was not involved in drafting the statement.

In detailed charts, the document gives scores of 1–9 to 166 indications for diagnostic catheterization procedures, which include left heart and right heart catheterization, ventriculography, and coronary angiography.

The statement recommends, in part, that diagnostic coronary catheterization is:

• Appropriate for patients with definite or suspected acute coronary syndromes; patients with planned vascular surgery; preoperative catheterization for coronary anatomy; and patients with symptomatic and severe valvular heart disease with discordant clinical and noninvasive imaging findings.

• Uncertain or inappropriate for asymptomatic and symptomatic coronary artery disease patients with low or intermediate pretest probability and patients without symptoms but with severe disease.

• Inappropriate for asymptomatic patients who have had prior noninvasive testing with low-risk findings and patients without symptoms with mild to moderate stenosis or concordant clinical and noninvasive findings.

"It is hoped that payers would use these criteria to ensure that their members receive necessary, beneficial, and cost-effective cardiovascular care, rather than for other purposes," according to the document. "It is expected that services performed for appropriate and/or uncertain indications will receive reimbursement," adding that services performed for inappropriate indications may require additional documents for payment due the unique nature of the patient circumstance. "This additional documentation should not be required for uncertain indications."

Dr. White said that they key message from appropriate use criteria documents is that "these are good for doctors, and they only become problems when they’re misinterpreted. ... This is a document for physicians to help them reduce variations in their practice," he said, adding, "We have to understand that underuse is as powerful as overuse."

In the document the panel has also developed a worksheet where referring physicians can check the reasons they want the procedure to be performed and the reasons the patient is being referred. "Our hope is eventually that we’ll have real-time tools that can help with decision support for physicians and patients when they’re making decisions not just about cardiac catheterization, but about other procedures and patient care," said Dr. Patel.

Dr. Patel had no relevant disclosures. Dr. White is on the editorial advisory board for Cardiology News.

Of 166 identified possible clinical scenarios that may warrant diagnostic catheterization, nearly half are appropriate, a third are uncertain, and about a quarter are inappropriate, according to the first document to detail the appropriate use criteria for the invasive cardiac procedure.

Cardiovascular care accounts for a substantial portion of Medicare and overall health care burden in the United States, so "the movement towards developing appropriate use criteria is to help inform when it’s reasonable to a do a procedure for both patients and clinicians who are referring for the procedure, and then payers who are thinking about understanding patterns of use," said Dr. Manesh R. Patel, cochair of the report’s writing committee, and an assistant professor and director of Catheterization Laboratory Research Program at Duke University.

The report was released on May 9 by the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI), in collaboration with a group of professional societies (J. Am. Coll. Cardiol. 2012 May 29 [doi:10.1016/jacc.2012.03.003]).

The diagnostic catheterization appropriate use criteria follow those focusing on coronary revascularization, released in January (J. Am. Coll. Cardiol. 2012 Jan. 20 [doi:10.1016/jacc.2011.12.001]).

"Many will ask, Why do we need this now?," said Dr. Patel. "In part, because the reality is, without us leading the field and developing criteria for use, others will do that for us, and this is an opportunity for us to show our professional responsibility," he said.

Appropriate use criteria reports in general help reduce variations in practice and improve quality of care, said Dr. Christopher J. White, president of SCAI and professor of medicine and chairman of the dept. of cardiovascular diseases at Ochsner Clinic, New Orleans.

The documents, however, are much softer and broader than guidelines and should not be looked at as rules, said Dr. White, who was not involved in drafting the statement.

In detailed charts, the document gives scores of 1–9 to 166 indications for diagnostic catheterization procedures, which include left heart and right heart catheterization, ventriculography, and coronary angiography.

The statement recommends, in part, that diagnostic coronary catheterization is:

• Appropriate for patients with definite or suspected acute coronary syndromes; patients with planned vascular surgery; preoperative catheterization for coronary anatomy; and patients with symptomatic and severe valvular heart disease with discordant clinical and noninvasive imaging findings.

• Uncertain or inappropriate for asymptomatic and symptomatic coronary artery disease patients with low or intermediate pretest probability and patients without symptoms but with severe disease.

• Inappropriate for asymptomatic patients who have had prior noninvasive testing with low-risk findings and patients without symptoms with mild to moderate stenosis or concordant clinical and noninvasive findings.

"It is hoped that payers would use these criteria to ensure that their members receive necessary, beneficial, and cost-effective cardiovascular care, rather than for other purposes," according to the document. "It is expected that services performed for appropriate and/or uncertain indications will receive reimbursement," adding that services performed for inappropriate indications may require additional documents for payment due the unique nature of the patient circumstance. "This additional documentation should not be required for uncertain indications."

Dr. White said that they key message from appropriate use criteria documents is that "these are good for doctors, and they only become problems when they’re misinterpreted. ... This is a document for physicians to help them reduce variations in their practice," he said, adding, "We have to understand that underuse is as powerful as overuse."

In the document the panel has also developed a worksheet where referring physicians can check the reasons they want the procedure to be performed and the reasons the patient is being referred. "Our hope is eventually that we’ll have real-time tools that can help with decision support for physicians and patients when they’re making decisions not just about cardiac catheterization, but about other procedures and patient care," said Dr. Patel.

Dr. Patel had no relevant disclosures. Dr. White is on the editorial advisory board for Cardiology News.