Inappropriate Tests Reduced With CT Quality-Improvement Program

Reed Miller

August 09, 2012

August 8, 2012 (Royal Oak, Michigan) — Continuous physician education and the threat of losing reimbursement coverage have dramatically reduced the number of inappropriate coronary computed angiography (CCTA) tests in Michigan, data from the Advanced Cardiovascular Imaging Consortium (ACIC) show [1].

"A collaborative effort like this, where we're constantly evaluating our own practice patterns and making continuous change, keeping up with the literature to see what's appropriate--that works," study leader Dr Kavitha Chinnaiyan (William Beaumont Hospital, Royal Oak, MI) told heartwire . Results of their study, showing a dramatic decrease in the percentage of CCTA tests deemed inappropriate by multisociety appropriate-use guidelines, are published online August 8, 2012 in the Journal of the American College of Cardiology.

Since the release of the 2006 multisociety appropriate-use guidelines on CCTA and cardiac magnetic resonance imaging, the ACIC, a statewide continuous-quality-improvement (CQI) initiative sponsored by the Blue Cross Blue Shield/Blue Care Network of Michigan, began studying the use of CCTA by about 5000 physicians at 47 Michigan centers--including imaging centers, community hospitals, and private hospitals. The ACIC then implemented a program of physician education and practice tracking at all of the 47 centers participating in the ACIC to try to improve compliance with the appropriate-use criteria (AUC).

The study includes data from 25 387 patients and compared practice patterns observed at the ACIC centers from July 2007 to June 2008--before the AUC education efforts began--with the practice patterns in the last six months of 2010.

Between the preintervention period of 2008 and follow-up period of 2010, there was a 23.4% increase in the percentage of CCTA tests performed at the ACIC centers that were appropriate according to the AUCs, from 61.3% of all tests to 80% of all tests. Meanwhile, there was a 60.3% decrease in inappropriate testing (14.6% to 5.8%) and a 40.8% decrease in the number of tests that fall in the uncertain category in the AUC (10.3% to 6.1%). Also, the number of CCTA scans that could not be classified based on the test records dropped 41.7%, from 13.9% to 8.1% (p<0.0001 for all comparisons).

Cardiologists improved their percentage of appropriate tests from 60.4% to 79.5% while decreasing their inappropriate tests from 13% to 5.2%. Internal-medicine and family-practice doctors were the group most likely to order an inappropriate scan, but the education efforts led them to increase their appropriate percentage from 51.1% to 70.4%, while cutting their rate of ordering inappropriate scans from 20.2% to 12.5%.

Emergency physicians had the best numbers to begin with but still improved: appropriate tests went up from 83.6% to 91.6% of all CCTA scans ordered by ER doctors, while inappropriate tests dropped from 9.1% to 0.6%. For all other categories, the appropriate rate grew from 61.1% to 83.2%, while the inappropriate rate dropped from 18.6% to 5.9% (p<0.0001 for all comparisons).

Education and Incentives to Change

The study was created to determine whether a widespread education effort could reduce excessive radiation doses from CCTA and eliminate the costs associated with unnecessary procedures, Chinnaiyan said. "We asked: How do we engage these physicians, and what kind of incentives are there to refer appropriate patients objectively, and do we see any change?"

From 2008 to 2010, the ACIC leadership conducted continuing-medical-education programs for physicians who refer patients for CCTA while also working directly with each center to help them track their use of CCTA and bring down the number of tests deemed inappropriate by the AUC. BlueCross/BlueShield advised the participating centers that they could lose reimbursement for imaging tests if they didn't show progress in reducing the number of inappropriate tests.

"This whole thing is a very collaborative effort between the payer and the physicians," Chinnaiyan said. "[BlueCross/BlueShield] were saying, 'We want you to make the right decision.' They didn't set specific parameters and say, 'You must do this,' but they said, 'We'd like to see a change because we can't sustain funding inappropriate studies.' "

She also noted that factors originating outside of Michigan probably played an important role in changing CCTA practice patterns within the ACIC. During the period of this study, the AUC movement "took the country by storm" while the risks associated with radiation from CCTA have also become a hot topic of conversation in the cardiology community. Under pressure from Congress, the Centers for Medicare and Medicaid Services has routinely targeted advanced imaging tests like CCTA for massive reimbursement cuts in recent years. Also, new AUC for CCTA, which incorporated new data and clarified recommendations that were previously ambiguous, were released in 2010.

This study was funded by Blue Cross/Blue Shield/Blue Care Network of Michigan. Chinnaiyan has no relevant disclosures.

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