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Appropriateness Criteria for Coronary Revascularization The Practice of Medicine is Already Over-Regulated and these Criteria Reflect Existing Guidelines Ted Feldman MD, FSCAI FACC FESC Evanston Hospital SCAI Annual Fellows Course Las Vegas December 5th-8th, 2012 Ted Feldman MD, FACC, FESC, FSCAI Disclosure Information The following relationships exist: Grant support: Abbott, BSC, Edwards, St Jude, WL Gore Consultant: Abbott, BSC, Coherex, Edwards, Intervalve, Diiachi Sankyo-Lilly, WL Gore Speaker: Boston Scientific Co-author of the Off label use 2005-2008 of products and investigational PCI devices will be discussed in this presentation Guideline statements December 2008 2008 * Atherosclerotic Peripheral Vascular Disease Symposium II o Executive Summary o Nomenclature for Vascular Diseases o Screening for Atherosclerotic Vascular Diseases: Should Nationwide Programs Be Instituted? o Vascular Magnetic Resonance and Computed Tomographic Imaging o Stroke Intervention: State of the Art o Controversies in Carotid Artery Revascularization o Controversies in Abdominal Aortic Aneurysm Repair o Lower-Extremity Revascularization: State of the Art o Intervention for Renal Arterial Disease * ADA/ACCF/AHA Intensive Glycemic Control and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA Diabetes Trials * Heart Disease and Stroke Statistics—2009 Update * 2008 Key Data Elements and Definitions for Cardiac Imaging * 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging November 2008 June 2009 1st HALF 2009 *Cardiovascular Evaluation and Management of Severely Obese Patients Undergoing Surgery *Exercise Training for Type 2 Diabetes Mellitus: Impact on Cardiovascular Risk *Mortality, Health Outcomes, and Body Mass Index in the Overweight Range *Recommendations for Clinical Exercise Laboratories May 2009 * * * * * ACC/AHA ACC/AHA ACC/AHA ACC/AHA ACC/AHA Classification of Care Metrics: Performance Measures and Quality Metrics 2008 Statement on Performance Measurement and Reperfusion Therapy 2008 Performance Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Full Text October 2008 * Post–Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and Prognostication * Standards for Measures Used for Public Reporting of Efficiency in Health Care * ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use September 2008 * 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease *Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen* Activator The American Heart Association's 2008 Statement of Principles for Healthcare Reform * Depression and Coronary Heart Disease: Recommendations for Screening, Referral, and Treatment *Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient * ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging August 2008 * The American Heart Association’s Principles for Comparative Effectiveness Research *AHA/ASA/ACCF Percutaneous Device Closure of Patent Foramen Ovale for Secondary Stroke Prevention: A Call for Completion of * AHA/ACCF/HRS Noninvasive Risk Stratification Techniques for Identifying Patients At Risk for Sudden Cardiac Death *Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome Randomized Clinical Trials *Ambulatory Blood Pressure Monitoring in Children and Adolescents: Recommendations for Standard Assessment *Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care *A Review of the Evidence for the Use of Telemedicine Within Stroke Systems of Care July 2008 *Definition and Evaluation of Transient Ischemic Attack April 2009 *Criteria for Evaluation of Novel Markers of Cardiovascular Risk *Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures March 2009 * AHA/ACCF Sleep Apnea and Cardiovascular Disease * ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis * Management of Stroke in Infants and Children * Translating Research Into Practice for Healthcare Providers: The American Heart Association’s Strategy for Building Healthier Lives, Free of Cardiovascular Diseases and Stroke * The Impact of Prevention on Reducing the Burden of Cardiovascular Disease June 2008 * Population-Based Prevention of Obesity: The Need for Comprehensive Promotion of Healthful Eating, Physical Activity, and Energy Balance * Childhood Obesity Research Summit Report * Noninvasive Coronary Artery Imaging: Magnetic Resonance Angiography and Multidetector Computed Tomography Angiography * Childhood Obesity Research Summit: Executive Summary * State of the Science Conference: Initiative to Decrease Cardiovascular Risk and Increase Quality of Care for Patients Living With * ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension HIV/AIDS: Executive Summary * 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults * Contribution of Metabolic and Anthropometric Abnormalities to Cardiovascular Disease Risk Factors Epidemiological Evidence for Cardiovascular Disease in HIV-Infected Patients and Relationship to Highly Active Antiretroviral * 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of*Heart Failure in Therapy Adults * Effects of HIV Infection and Antiretroviral Therapy on the Heart and Vasculature * Implementing American Heart Association Pediatric and Adult Nutrition Guidelines * Screening and Assessment of Coronary Heart Disease in HIV-Infected Patients February 2009 * Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis * AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram o Part III: Intraventricular Conduction Disturbances o Part IV: The ST Segment, T and U Waves, and the QT Interval o Part V: Electrocardiogram Changes Associated With Cardiac Chamber Hypertrophy o Part VI: Acute Ischemia/Infarction * Ionizing Radiation in Cardiac Imaging January 2009 * * * * * Omega-6 Fatty Acids and Risk for Cardiovascular Disease Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage Progress and Challenges in Metabolic Syndrome in Children and Adolescents ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization Partnering to Reduce Risks and Improve Cardiovascular Outcomes * * * * Development of Appropriate Coronary Heart Disease Risk Prediction Models in HIV-Infected Patients Prevention Strategies for Cardiovascular Disease in HIV-Infected Patients Wallet Card, ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities ACC/AHA Pocket Guideline Based on the ACC/AHA/HRS 2008 Guidelines "Device-Based Therapy of Cardiac Rhythm Abnormalities" May 2008 * * * * Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring: Executive Summary Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring: Full Text ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Executive Summary ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Full Text April 2008 * Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Medications for Attention Deficit/Hyperactivity Disorder * Essential Features of Designating Out-of-Hospital Cardiac Arrest as a Reportable Event * Resistant Hypertension: Diagnosis, Evaluation, and Treatment * Prevention of Heart Failure March 2008 * Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest * Management of Cocaine-Associated Chest Pain and Myocardial Infarction * Percutaneous and Minimally Invasive Valve Procedures * Update to the AHA/ASA Recommendations for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack * ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography February 2008 * Hyperglycemia and Acute Coronary Syndrome * ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter January 2008 * Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines Level of Evidence A in only 12% Study Question: What is the evolution of recommendations in ACC/AHA cardiovascular guidelines and the distribution of recommendations in relationship to the levels of evidence? Methods: Fifty-three guidelines on 22 topics, including a total of 7,196 recommendations, were abstracted. Quantity, yes!! The proportion of recommendations forso whichmuch…. there is no Quality, not conclusive evidence is also growing. Conclusions: Recommendations in current ACC/AHA practice guidelines are largely developed from lower levels of evidence or expert opinion. • These findings highlight the need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith CS Jr. JAMA 2009;301:831-841 Disclaimer? First, PCI is a technique that has been continually refined and modified; hence, continued, periodic guideline revision is anticipated. Second, these guidelines are to be viewed as broad recommendations to aid in the appropriate application of PCI. Under unique circumstances, exceptions may exist. • The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all of the circumstances presented by that patient. These guidelines are intended to complement, not replace, sound medical judgment and knowledge. Use Judgement Follow Guidelines What is the Gold Standard?? Guidelines Performance measures Appropriateness criteria Standard of practice in the community FDA labeling CMS reimbursement Private insurance coverage policy ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization Manesh, R.P. et al. J. Am. Coll. Cardiol. published online Jan 5, 2009 The Role of Appropriate Use Criteria for Coronary Revascularization AUC are developed to determine whether a particular approach to care is reasonable in a given clinical scenario. This is partly in response to a growing concern from payers and patients regarding the potential overuse or misuse of advanced technologies for cardiovascular care. In some areas of practice guidelines, the level of evidence is reduced to group consensus due to the lack of “hard” data from randomized controlled trials. The same holds true for cardiac catheterization and coronary revascularization when one tries to extrapolate and apply study findings to real world scenarios. For this reason, there is substantial variation in the application of these procedures. 2009;53;554-555 J. Am. Coll. Cardiol. W. Douglas Weaver, Timothy J. Gardner, and Joseph D. Babb Unlike prevention and treatment strategies supported by evidence-based practice guidelines, the evidence base for imaging is anecdotal, fragmented, and lacking in prospective clinical trials. Appropriateness Criteria for Coronary Revascularization scored on a scale of 1 to 9 • Scores of 7 to 9 indicate that revascularization was considered appropriate and likely to improve health outcomes or survival • Scores of 1 to 3 indicate revascularization was considered inappropriate and unlikely to improve health outcomes or survival • Mid range (4 to 6) indicates likelihood that coronary revascularization would improve health outcomes or survival was considered uncertain. 17-member technical panel • 4 interventional cardiologists, 4 CVr surgeons, 8 cardiologists, others who treat patients with cardiovascular disease, health outcome researchers, and 1 medical officer from a health plan underuse was common (57% according to panel A and 71.3% according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure. Ko DT J Am Coll Cardiol 2012 Cardiac Care Network Ontario Variations in Revascularization Practice in Ontario Working Group Guidelines simplified?? Appropriateness Criteria for Coronary Revascularization Manesh, R.P. et al. J. Am. Coll. Cardiol. published online Jan 5, 2009 The Megapixel Myth 8.1 Megapixel Digital Camera For normal 4x6 prints, even VGA is just fine. Digital cameras did this back in 1991! Sharpness depends more on your photographic skill than the number of megapixels Sharpness has little to do with image quality, and resolution has little to do with sharpness. Resolution (pixel count) has nothing to do with picture quality. Color and tone are far more important technically. The megapixel myth was started by camera makers and swallowed hook, line and sinker by camera measurebators. Camera makers use the number of megapixels a camera has to hoodwink you into thinking it has something to do with camera quality. However, it is critical for everyone and especially payers to understand that the AUC were never intended to be the final answer in determining payment for procedures ACC/AHA 2013 Guidelines for the Management of Guidelines Guidelines Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI TASK FORCE MEMBERS Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI, Gregory J. Dehmer, MD FACC FSCAI GUIDELINE S Practice simplified??