Noninvasive cardiovascular imaging in U.S. medical practice today raises two policy challenges, according to a statement released on Feb. 17 by the American College of Cardiology and 13 collaborating medical groups: fostering a volume of imaging that balances patient needs with responsible use of societal resources, and continued improvement in the quality of care based on noninvasive cardiovascular imaging.
"The purpose of this document is to provide a brief exposition of the issues involved [in usage volume of noninvasive cardiovascular imaging] and the possible ways in which the medical care system can balance responsible use of imaging with patient safety concerns while maintaining or even enhancing quality of care," wrote the 20-member panel in a health policy statement (J. Am. Coll. Cardiol. 2014;63:698-721). "Policy makers must take into account the complex interplay between medical care quality (of which proper use of diagnostic testing is an integral part), patient health outcomes, and medical costs," said the statement’s panel, which included representatives from the American Society of Nuclear Cardiology, the American Society of Echocardiography, the Radiological Society of North America, and six other imaging groups.
"The current situation in noninvasive cardiovascular imaging is pretty much unsatisfactory from everyone’s point of view," said Dr. Daniel B. Mark, a cardiologist and professor of medicine at Duke University in Durham, N.C., who chaired the statement-writing committee."However, it is encouraging that we now have much more knowledge and several new informatics tools that can be used to help us apply that knowledge. We have many of the ingredients needed to create a more responsible, cost-conscious approach to imaging that still preserves – at its core – patient-physician decision making," said Dr. Mark in a written statement.
Over the past 20 years, U.S. health care payers implemented three main strategies to control expenditures for diagnostic imaging, the statement said: requiring prior authorization from a radiology benefits manager; requiring prior notification before performing selected, advanced diagnostic imaging methods like MRI and PET; and reduced payments for imaging. The statement characterized all three as "blunt instruments,’ and added these can lead to "limited patient access to necessary services and greater administrative inefficiencies."
One approach that would likely improve imaging-use policy is an "iterative process" that uses high-quality data to guide development of policy interventions with the potential to reduce imaging overuse, underuse, and misuse. Another approach the panel endorsed is integration of appropriate-use software into the process of care. "Development of computerized appropriate-use tools would be efficient and also greatly enhance transparency," the panel said. "Validated patient-specific point-of-care/referral appropriateness tools and other decision-support tools are examples of innovations that could support a higher-quality, more accountable use of cardiovascular imaging."
Recent data show that growth of advanced cardiovascular imaging has substantially slowed since 2006, likely because of a combination of professional society and payer initiatives. "Many clinicians and patients fear that imaging policy decisions will continue to be driven primarily, if not exclusively, by cost considerations without adequate consideration of clinical benefit and value," said the statement.
"The complexity of our current health care system and the competing macro-forces that push it in myriad different directions can make responsible imaging use seem impossibly daunting. What we need is a convergence of will from all key stakeholders to make it happen. This statement is hopefully a step in that direction," Dr. Mark said.
Dr. Mark said that he had no disclosures.
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