With Updated Use Criteria, 30% of Echo Tests Inappropriate

February 22, 2013

MIAMI — A study evaluating the utilization of stress echocardiography at one academic institution demonstrated that revisions to the older American College of Cardiology (ACC) appropriate-use criteria enabled almost all previously unclassifiable stress echocardiograms to now be classified [1]. This suggests that the updated 2011 criteria have increased value as both a decision aid for clinicians and a guide to reimbursement judgments by health plans, say researchers.

However, the updated criteria do not appear to have had an impact on the number of imaging tests requested for inappropriate reasons. Approximately one-third of stress-echocardiographic tests were ordered for inappropriate indications.

"The revised criteria represent improvements that may potentially help clinicians as well as health plans using them in decision making. However, we were not able to demonstrate that the publication of the new appropriate-use criteria had a substantial impact on utilization practices, at least in our institution," lead investigator Dr Howard Willens (University of Miami Miller School of Medicine, FL) told heartwire . "Two iterations of the criteria, as well as a casual education initiative, did not impact utilization over a three-year period."

In addition, the researchers found only a moderate degree of correlation between the 2008 and 2011 appropriate-use criteria for stress echocardiography and the radiology benefits' manager (RBM) precertification guidelines. According to their analysis, 12.9% and 41.9% of the stress-echo cases classified as appropriate or uncertain using the 2008 criteria would not have received preauthorization according to the guidelines of the companies evaluated in this report.

"There is a need for more consistency between the health plan precertification guidelines for stress echocardiography and the carefully written, scientifically based appropriate-use criteria," said Willens.

In an editorial accompanying the study [2], Dr James Min (Cedars-Sinai Medical Center, Los Angeles, CA) explains that RBMs are used by private payer plans and require preauthorization of coronary artery disease imaging tests such as stress echocardiography to ensure coverage. Although the RBMs are supposedly based on the ACC appropriate-use criteria, they have been criticized for differences between the ACC criteria and the RBM guidelines. Given that the correlation between the RBM and ACC criteria was only fair, this lack of consistency can be frustrating for physicians.

However, Min writes that although are indeed drawbacks to the RBM process, allowing carte-blanche ordering of imaging tests--the penchant for using noninvasive testing modalities has resulted in an "unbridled consumption of coronary artery disease imaging resources," he notes--is problematic. He cites the evidence that the number of inappropriate indications for stress echo did not decline in the study by Willens and colleagues, with approximately one-third of the tests ordered for inappropriate indications.

The debate over just what percentage of echocardiograms are medically needed is gaining lots of attention these days, including a lively discussion on the theheart.org following a blog post by editor in chief Dr Eric Topol (Scripps Translational Science Institute, La Jolla, CA). As Min notes in his editorial, the use of diagnostic imaging is increasing more rapidly than other aspect of care, with noninvasive stress echo increasing 6.1% annually between 1993 and 2001.

Assessment of the 2008 and 2011 Criteria

In the study, published online February 20, 2013 in the Journal of the American College of Cardiology: Cardiovascular Imaging, Willens, along with Drs Katarina Nelson and Robert Hendel (University of Miami Miller School of Medicine), sought to evaluate the utilization of stress echo at their institution and to evaluate the impact of the updated 2011 appropriate-use criteria on the number of studies classified as appropriate, inappropriate, or unclassifiable.

The study was a retrospective analysis of the electronic medical records of the University of Miami Health System. In total, they assessed the appropriateness of 209 stress-echo tests ordered over a two-month period in 2008, 209 stress-echo tests ordered after the publication of the revised 2011 appropriate-use criteria, and 111 stress-echo tests ordered in 2011 after a two-week education initiative designed to highlight the new appropriate-use criteria. The educational initiative consisted of a grand-rounds lecture and a discussion of the five most common inappropriate indications for stress-echo testing.

Using the 2011 appropriate-use criteria, 43.5% of the 529 stress-echo tests were requested for appropriate indications, 22.9% for uncertain indications, and 30.8% for inappropriate indications. The evaluation of an ischemic equivalent with a low pretest probability of coronary disease, an interpretable electrocardiogram, and the patient having an ability to exercise were the most common inappropriate indications. To heartwire , Willens said the appropriate-use utilization pattern did not change between 2008 and 2011, nor did it improve after the educational initiative.

"I think the reason for this is that the educational initiative has to be more intense," he said. "It can't just be a lecture and providing a list of inappropriate indications. It has to be more interactive, something with more feedback to the physicians."

When the researchers applied the 2011 appropriate-use criteria to stress-echo tests ordered in 2008, 25% of the tests were reclassified using the updated criteria. The number of unclassifiable studies declined from 9.6% to 1.0%, although the number of stress-echo tests classified as appropriate and inappropriate was similar using the 2008 and 2011 appropriate-use criteria. This demonstrates the potential increased value of the updated criteria. Regarding the moderate correlation between the RBM and the appropriate-use criteria, Willens said that physicians can appeal to the medical director of an RBM if an imaging test is denied, but such appeals are onerous and costly.

"It is very a labor-intensive process, which costs time and money on the provider's side, and this does increase the cost of running a practice," said Willens.

In the editorial, Min said the study by Willens et al is an important one, but some caveats apply, namely that the research is based on data from a single academic center. As a result, generalizability to other nonacademic settings might be difficult. This is an important point, as the majority of imaging tests are ordered in these nonacademic settings. In addition, the appropriate-use criteria were compared with only two RBMs that had criteria available on the internet. It is possible that other unpublished RBMs might be in better agreement with the ACC appropriate-use criteria, writes Min.