appropriate use criteria for coronary revascularization- updates 2012

Abdelkader Almanfi , MD, MRCP-UK

Texas Hear t Institute

May 9th

2013

Appropriate Use Criteria for Coronary Revascularization

Objective

Help you to use the 2012 Appropriate Use Criteria (AUC) for Coronary Revascularization to improve the care of your patients

AUC: What Did You Mean?―AUC‖ could mean Area Under the Curve (Receiver Operating Characteristic Curve;

pharmacokinetic curve) The 2009 JACC/Circulation Paper on Appropriateness Criteria for

Coronary Revascularization The 2012 Appropriate Use Criteria for Coronary Revascularization

Focused Update Bedside assessment of the appropriateness of PCI or CABG for a given

patient A score (or statistics about scores) from the NCDR CathPCI Registry

or other vendors

Appropriateness Criteria, 2009

Developed as a supplement to ACC/AHA Guideline documents.

Appropriateness criteria are designedto examine the use of diagnostic and therapeutic

proceduresto support efficient use of medical resourcesduring the pursuit of quality medical care

Patel, et al. JACC 2009; 53:530-553

Patel, et al. JACC 2009; 53:530-553

The WritingCommittee

Extensive literature review and synthesis

of the evidence

What are the known indicationsfor coronary revascularization?

- Major randomized trials- Guidelines- Other sources

Current understanding of technical capabilities and potential patient benefits of the procedures examined

Appropriateness review of ~180* common clinical scenarios encountered in everyday practice in which coronary revascularization is frequently considered

*Did not include every conceivable situation (>4,000 possible scenarios)


Appropriateness Criteria: Intended to assist patients and clinicians Not intended to diminish the difficulty or uncertainty

of clinical decision making Cannot act as substitutes for sound clinical judgment

and practice experience Allow assessment of utilization patterns for a test or

procedure, including across providers


Patel, et al. JACC 2009; 53:530-553

―The ACCF and its collaborators believe that an ongoing review of one’s practice using these criteria will help guide a more effective, efficient, and equitable allocation of health care resources, and ultimately, better patient outcomes.‖


Patel, et al. JACC 2009; 53:530-553

Scenarios scored by a technical panel (17 members in a modified Delphi exercise) on a scale of 1-9.

Scores 7-9: Appropriate, revascularization likely to improve health outcomes or survival

Scores 4-6: Uncertain, likelihood that revascularization would improve health outcomes or survival was considered uncertain

Scores 1-3: Inappropriate, revascularization unlikely to improve health outcomes or survival

Health outcomes: symptoms, functional status, and/or quality of life

Patel, et al. JACC 2009; 53:530-553

Appropriateness Criteria:2009 Methodology

In other words

Scores 7-9: Appropriate, revascularization is generally acceptable and is a reasonable approach for the indication

Scores 4-6: Uncertain, revascularization may be acceptable and may be a reasonable approach for the indication, but more research and/or patient information is needed to classify the indication definitively

Scores 1-3: Inappropriate, revascularization is notgenerally acceptable and is not a reasonable approach for the indication

Patel, et al. JACC 2009; 53:530-553

Appropriateness Criteria:2009 Methodology

Patel, et al. JACC 2009; 53:530-553

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CCS Class IV

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High

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Appropriateness Criteria: Key Variables

Appropriate Use Criteria for Coronary Revascularization Focused Update 2012

Endorsed by:

AUC 2012

Reassessment of clinical scenarios felt to be affected by significant changes in the medical literature or gaps from prior criteria

A practical standard upon which to assess and better understand variability in the use of cardiovascular procedures

Patel, et al. JACC 2012; 59:

AUC 2012: The Fine Print

Significant coronary stenosis: LMCA stenosis ≥50% luminal diameter narrowing

in the worst view by visual assessment Epicardial non-LMCA stenosis ≥70% luminal

diameter narrowing in the worst view by visual assessment

“Borderline” coronary stenosis: Epicardial non-LMCA stenosis 50-60% luminal

diameter narrowing


Assumptions No other CAD present except as specified in the

clinical scenario. All patients are receiving standard care,

including guideline-based risk factor modification for primary or secondary prevention

Operators performing PCI or CABG have appropriate clinical training and experience and have satisfactory outcomes as assessed by quality assurance monitoring



Assumptions PCI or CABG is performed in a manner consistent with established standards

of care. No unusual extenuating circumstances exist, e.g.,

inability to comply with antiplatelet agents do not resuscitate status patient unwilling to consider revascularization technically not feasible to perform revascularization comorbidities likely to markedly increase procedural

risk substantially



Maximal Anti-Ischemic Medical Therapy: the use of at least 2 classes of therapies to reduce anginal symptoms

Risk of Findings on Noninvasive Testing Low-Risk (<1% annual cardiac mortality) Intermediate-Risk (1-3% annual cardiac mortality) High-Risk (>3% annual cardiac mortality)



High Risk Findings on Noninvasive Testing Severe resting left ventricular dysfunction (LVEF <35%) High-risk treadmill score Severe exercise left ventricular dysfunction (exercise LVEF <35%) Stress-induced large perfusion defect (particularly if anterior) Stress-induced multiple perfusion defects of moderate size Large, fixed perfusion defect with LV dilation or increased lung

uptake (thallium-201) Stress-induced moderate perfusion defect with LV dilation or

increased lung uptake (thallium-201) Echocardiographic wall motion abnormality (involving greater than

two segments) developing at low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)

Stress echocardiographic evidence of extensive ischemia



Intermediate Risk Findings on Noninvasive Testing

Mild/moderate resting left ventricular dysfunction (LVEF = 35% to 49%)

Intermediate-risk treadmill score Stress-induced moderate perfusion defect without

LV dilation or increased lung intake (thallium-201)

Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving less than or equal to two segments



Low Risk Findings on Noninvasive Testing Low-risk treadmill score Normal or small myocardial perfusion defect at rest

or with stress* Normal stress echocardiographic wall motion or no

change of limited resting wall motion abnormalities during stress*

* Although the published data are limited, patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting left ventricular dysfunction (LVEF <35%)



Classification of Chest Pain Typical Angina (Definite):

Substernal chest pain or discomfort Provoked by exertion or emotional stress Relieved by rest and/or nitroglycerin

Atypical Angina (Probable):

Lacks one of the characteristics of definite or typical angina

Nonanginal Chest Pain:

Meets one or none of the typical angina characteristics



Canadian Cardiovascular Society (CCS) Classification of Angina Pectoris

CCS I: Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.

CCS II: Slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.



Canadian Cardiovascular Society (CCS) Classification of Angina Pectoris

CCS III: Marked limitations of ordinary physical activity. Angina occurs on walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace.

CCS IV: Inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.



TIMI Risk Score for Patients With Suspected Acute Coronary Syndrome

1 point per item Age ≥65 years ≥ 3 Risk Factors for CAD Diabetes mellitus; Cigarette smoking; Hypertension (BP 140/90 mm Hg or on antihypertensive

medication); Low HDL cholesterol (<40 mg/dL); Family history of premature CAD (CAD in

male first-degree relative, or father less than 55, or female first-degree relative or mother less than 65)



TIMI Risk Score for Patients With Suspected Acute Coronary Syndrome, continued

1 point per item

Known CAD (stenosis ≥50%) Aspirin Use in Past 7 days Severe angina (≥2 episodes within 24 hrs) ST segment deviation ≥0.5 mm Elevated Cardiac Myonecrosis Biomarkers



TIMI Risk Score for Patients With Suspected Acute Coronary Syndrome

Low Risk (0-2): 4.7-8.3% risk of death or ischemic events through 14 days

Intermediate Risk (3-4): 13.2-19.9% risk of death or ischemic events through 14 days

High Risk (5-7): 26.2-40.9% risk of death or ischemic events through 14 days



AUC 2012: What’s New15 Updated Indications


13 scenarios for acute coronary syndromes 36 scenarios for non-ACS without prior bypass

surgery 12 scenarios for non-ACS with prior bypass

surgery 8 scenarios for advanced CAD, CCS III or IV,

and/or intermediate- to high-risk findings on non-invasive testing

AUC 2012: The Whole Thing69 Categories of Indications


AUC 2012: At the Bedside


SCAI AUC 2012 Tool

Limitations of the AUC

―Maximal antianginal medical therapy is defined as the use of at least 2 classes of therapies to reduce anginal symptoms.‖–intolerance, allergies, resting heart rate and blood pressure are not taken into account.

Inter-rater variability in coding the results of non-invasive testing for low, intermediate and high risk.


Challenges in Documentation of the AUC Inputs

Insufficient primary documentation to assess CCS class (e.g., ―worsening exertional angina‖)

Lack of documentation of formal evaluation of CCS class by a cardiologist (which leads to inter-rater variability in imputing CCS class from the clinical documentation and thus difficulties with audits of CCS class against source documentation).

Improving Your AUC Results

CathPCI Registry AUC algorithm is proprietary. Nonetheless, you can improve your AUC scores by Improving clinical documentation of symptom precipitants

and non-invasive test results Formally documenting assessment of CCS class and

severity/risk of non-invasive test results (which makes life easier for your CathPCI data abstractors)

Assess AUC at the bedside prior to undertaking a coronary revascularization

Documenting thoroughly for cases rated to be of uncertain or inappropriate appropriateness

AUC 2012: In a Nutshell

The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

The AUC are intended to evaluate overall patterns of care regarding revascularization rather adjudicating specific cases.

It is not anticipated that all physicians or facilities will have 100% of their revascularization procedures deemed appropriate.


The use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was felt to be appropriate (or appropriate or uncertain).

Revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably.



There may be clinical situations in which a use of coronary revascularization for an indication considered to be appropriate does not always represent reasonable practice, such that the benefit of the procedure does not outweigh the risks.



The rating of a revascularization indication as inappropriate or uncertain should not preclude a provider from performing revascularization procedures when there are patient- and condition-specific data to support that decision. Indeed, this may reflect optimal clinical care, if supported by mitigating patient characteristics.



Uncertain indications require individual physician judgment and understanding of the patient to better determine the usefulness of revascularization for a particular scenario. The ranking of uncertain (4 to 6) should not be viewed as excluding the use of revascularization for such patients.



When a procedure is classified as ―Uncertain‖ it generally means one of two things

1. There was insufficient clinical information in the scenario. For example:

What would you do if:

This were an 85 y/o patient with typical age-related limitations?

This were a 35 y/o firefighter?

Uncertainty about “Uncertain”


1. There was insufficient clinical information in the scenario.

2. There is not a substantial literature base upon which to make a firm recommendation

No randomized trials on: This were an 85 y/o patient with typical age-related limitations?This were a 35 y/o firefighter?



1. There was not enough clinical information in the scenario.

2. There is not a substantial literature base upon which to make a firm recommendation

Is there literature that identifies the correct treatment for this?


JAMA June 6, 2011

Appropriateness: How do we rate?

NCDR Data July 1, 2009 thru Sept 30, 2010

Appropriateness mapping done by MAHI

500,154 PCI procedures at 1091 facilities

355,417 (71%) Acute:

STEMI, NSTEMI, High-risk UA

144,737 (29%) Non-acute:

Appropriateness: How do we rate?

From: WSJ July 6, 2011


Did the Media Get it Right?

Variation in Hospital Rates of Inappropriate PCIs for Non-Acute Indications

JAMA June 6, 2011

What Can You Do?

Make certain you understand ―uncertain‖ More importantly, make sure those entering your NCDR

data are entering variables correctly Develop an action plan to evaluate patients graded as

inappropriate and uncertain NCDR facilities can get a detailed listing of patients with these

classifications.

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appropriate use criteria for coronary revascularization- updates 2012

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