Journal of American College of Cardiology: CME Contributes to Reduction in CT Scans

by Thomas Sullivan, Editor

Implementing a collaborative quality initiative, including a continuing medical education (CME) program, can reduce inappropriate use of cardiac CT angiography (CCTA) by 60 percent, according to results of a recent study published online in the Journal of the American College of Cardiology.  All referring physician specialties lowered inappropriate use rates in the study. 

“The study suggests that voluntary, mutually established quality metrics reinforced by education and feedback can result in major changes in inappropriate use,” Chinnaiyan said in a release. “This collaborative approach involving physicians, hospitals and payers may be applied beyond CCTA to enhance value in other areas of medicine.”

Kavitha M. Chinnaiyan, MD, director of advanced cardiac imaging education at Beaumont Health System in Royal Oak, Mich., and colleagues designed the prospective, observational study to evaluate the effectiveness of a statewide continuous quality initiative called the Advanced Cardiovascular Imaging Consortium (ACIC), which is sponsored by Blue Cross/Blue Shield of Michigan and includes 47 centers that perform CCTA.

“CCTA is a useful tool for defining the presence and severity of luminal stenosis in patients with suspected coronary artery disease (CAD). CAD is the most common form of heart disease in the U.S., according to the Centers for Disease Control and Prevention (CDC), and the leading cause of morbidity.  As a consequence, physicians may turn to exams such as CCTA to ensure against misdiagnoses.”

The article noted, however, that “using imaging as a crux has led to overuse and higher healthcare costs.”  For instance, the average cost of a CCTA ranges between $500 and $1,500, according to Blue Cross/Blue Shield of Michigan.  Reducing inappropriate use of CCTA, therefore, “would improve care while lowering costs for payers and the healthcare system.”

Chinnaiyan and colleagues collected data on 25,387 patients enrolled at centers participating in the consortium between July 2007 and December 2010.  The study span covered pre-intervention, intervention and follow-up periods.  To determine appropriate use, they applied criteria from the 2006 multisocietal guidelines (J Am Coll Cardiol 2006;48:1475-1497).  After data collection they used to 2010 updated criteria.

The intervention included:  

• A site-specific intervention led by clinical champions;
• An educational plan that included conferences with CME credits;
• Site-specific activities such as grand rounds and letters about imaging overuse and the possibility of losing third-party payer coverage in the absence of change; and
• Data monitoring that provided feedback on appropriate use adherence and a comparison to consortium members as a whole. 

Patients in the follow-up study group had higher coronary risk factors compared with those in the pre-intervention group and a higher percentage of normal coronary arteries.

Researchers reported a 60.3 percent decrease in inappropriate use, from 14.6 percent in the pre-intervention group to 5.8 percent in the follow-up group.  The rate of inappropriate use of CCTA decreased among all referring provider specialties.  In cardiology, inappropriate use changed from 13 percent in the pre-intervention period to 5.2 percent.  The changes in internal medicine/family practice and emergency medicine were 20.2 percent to 12.5 percent and 9.1 percent to 0.6 percent, respectively.

The authors noted that CCTA’s high sensitivity and negative predictive value is a strength, particularly for ruling out CAD.  The slight increase in normal coronary arteries in the follow-up group proved indirect evidence of a corresponding increase in the appropriate selection of patients, they proposed.

The study lacked a control group, and factors beyond the consortium such as the recession or regulatory actions may have contributed to the trend to curb overuse of CCTA, the researchers wrote. They concluded that while building such a consortium is complex and requires resources, it has implications beyond CCTA.

“Although the ACIC is a complex undertaking requiring resource organization at every level of the process (referral, scheduling, point-of-care and follow-up), such collaborative partnerships between payers and physicians could result in similar successes on larger scales,” Chinnaiyan and colleagues concluded.