Appropriateness in cardiology

Transcription

1 Bruxelles, September 3rd, 2009 Appropriateness in cardiology Eugenio Picano Istituto di Fisiologia Clinica, CNR, Pisa

2 US Health Care Plan 1964 Don t ever argue with me. I ll go a hundred Million or a billion on health or education. I don t argue about Lady Bird buying flour.you got to have flour and coffee in your house and education and health. I ll spend the goddamn money. I may cut back some tanks. But not on health The success of health care reform rests on the plan s ability to slow spending growth and make health care affordable to everyone.

3 Cardiac Imaging 2009 The Renaissance (in front of the image) Costs and Risks (behind the image) The lost appropriateness The reasons of inappropriateness The Ulysses syndrome of the patient The Homer syndrome of the doctor

4 The Reinassance of Imaging billion imaging examinations in (UNSCEAR 2000) Estimated 5 billion in 2006 (APB infosense)

5 Alan Greenspan: health costs on an unsustainable trajectory (20% of GDP by 2016) Increase (x) Year 2006 = 1 0 Estimated number in UK (2006) per million population 1,7 3,4 2 MPI Stress echo MRI CT (n=2000) (n=165) (n=200) (n=50) Redrawn from Gershlick et al Heart 2007 A Report of British Cardiovascular Society Work ing Group

6 Cardiac Imaging 2009 The Renaissance (in front of the image) Costs and Risks (behind the image) The lost appropriateness The reasons of inappropriateness The Ulysses syndrome of the patient The Homer syndrome of the doctor

7 Cost of Cardiac Imaging 20 19, ,03 14 COST ,51 4 3,1 3, Echo CT SPECT CMR PET Heart cath Pennell D et al, Eur Heart J 2004

8 Behind the image Diagnostic X-rays msv 50 Nuclear Medicine 2,500 for AHA for AHA 2009 Coronary stenting Cardiac MSCT Thallium 201 Scan Tc-99m MIBI Scan 5 Renal Scan 150 for AHA 2009 = 2.4 msv Coronary calcium score Lung Perfusion Natural background radiation (1 year) Skull 0. 5 Chest 0.02 Medical Imaging Guidelines, 2001 (Picano E, Am J Med, 2003)

9 Picano E, BMJ 9 October 2004, updated with BEIR VII, 2006 Additionalriskof cancer/exam 1 in in 1,000 Female child <1 year Male child <1 year Adult woman Adult man Risk of cancer (fatal and non-fatal) for exposure to one 64-slice coro-ct Elderly: 1 in 1,500 Adult man: 1 in 750 Adult woman: 1 in 500 Male child (<1 year): 1 in 200 Female child (<1 year): 1 in 100 Elderly 1 in 10, Equivalent number of chest x-rays

10 Cardiac Imaging 2009 The Renaissance (in front of the image) Costs and Risks (behind the image) The lost appropriateness The reasons of inappropriateness The Ulysses syndrome of the patient The Homer syndrome of the doctor

11 Risk vs Benefit: The code of appropriateness B>>>R I (appropriate indication) B>>R IIa (probably appropriate) B R IIb (possibly appropriate) R B III (inappropriate) AHA-ACC-ESC Guidelines 2007

12 Cardiac imaging: paradox of plenty Stress echocardiography 32% 6% 62% Inappropriate Appropriate Partially inappropriate Stress Scintigraphy 11% 64% 25% Picano E, Marwick TH. Am Heart J 2007 Gibbons, Pellikka et al. JACC 2008 GREEN, non-ionizing RED, ionizing R. Redberg. The imperative of appropriateness. Am Heart J, 2007 R. Bonow Is Appropriateness appropriate? JACC 2008

13 Cardiac Imaging 2009 The Renaissance (in front of the image) Costs and Risks (behind the image) The lost appropriateness The reasons of inappropriateness The Ulysses syndrome of the patient The Homer syndrome of the doctor

14 The industry: Auri sacra fames Technology in medicine is frequently untested scientifically, often applied without data relating to cost benefit, and driven by market forces rather than by patient needs Bernard Lown, 2004

15 The Mother of all inappropriateness A draft proposal calls for a five-year phasein of global payments, with the amount per person set by age, gender, and health status. 42% July 27, 2009 BUSINESSWEEK Increase in state spending on health insurance since reforms institued in 2006 Data: Massachussetts reports

16 Cardiac Imaging 2009 The Renaissance (in front of the image) Costs and Risks (behind the image) The lost appropriateness The reasons of inappropriateness The Ulysses syndrome of the patient The Homer syndrome of the doctor

17 The patient s view: Ulysses Syndrome PETdipyridamole MRIadenosine 1250 Perfusion scintigraphy Stress echo 750 MSCT Contrast echo Cardiologist Coronary angiography and stenting Ithaca Troy Transthoracic Echo Total cost: >20,000 Total radio load: 4,000 CXR s (Bedetti G, et al, B J Radiol 2008) Total serious complication load: 5% (contrast + gadolinium+stress+cath+radiation-induced cancer)

18 Screening for atherosclerosis: thinking big Americans at risk and asymptomatic Non-invasive imaging Invasive Dx withrx Increasing intensity of treatment Non-invasive, Non-imaging Modificato da

19 Screening for 50 million Americans: Prevention for all? Dose CXr Risk per exam New cancers/year Vascular echo Stress echo MRI CACS-CT in ,000 Coronary angiography in ,000 Stress SPECT MIBI in ,000 MSCT 64 slice in ,000 AHA 2009 BEIR VII, 2006 An information that all (including patients) should know, and all (including physicians) do ignore

20 Diagnostic friendly fire on patient 200 Equivalentchestx-raysper head/per year Natural worldwide background exposure Nuclear Medicine Radiology (0.54 msv) (2.4 msv/year) (0.6 msv) (2.15 msv) (3.2 msv) Cardiac: 85% Cardiac: 60% USA USA GERMANY USA Modified and updated (Regulla D 2005, and Mettler FA 2007) from Picano E. BMJ, March

21 From medical radiation dose to cancer risk 10.0? Attributablecancerrisk (%) Update radio Add nuclear Accept BEIR VII 1.5 Source: Doll R and Peto R, 1981 Berrington de Gonzales and Darby, LANCET, Picano E, Lancet, letter 2004

22 Volume 357: November 29, 2007 Number 22 Computed Tomography - An Increasing Source of Radiation Exposure David J. Brenner, Ph.D., D.Sc., and Eric J. Hall, D.Phil., D.Sc. It has been estimated that about 0.4% of all cancers in the United States may be attributable to the radiation from CT studies. By adjusting this estimate for current CT use, this estimate might be nowin the range of 1.5 to 2.0%.

23 Volume 357: November 29, 2008 Number 22 Pay Now, Benefits May Follow - The Case of CT Angiography Rita F. Redberg, M.D., and Judith Walsh, M.D., M.P.H.. The use of cardiac imaging has been increasing by 26% per year, despite a lack of evidence of outcome benefit. Without suchevidence, a high-resolution cardiacct angiographic image of the heart is just another pretty picture

24 Cardiac Imaging 2009 The Renaissance (in front of the image) Costs and Risks (behind the image) The lost appropriateness The reasons of inappropriateness The Ulysses syndrome of the patient The Homer syndrome of the doctor

25 Deep impact of useless imaging EURATOM Law Royal College Radiology Medical Imaging Referral guidelines National Guidelines American College Radiology IAEA Why should we reduce inappropriate tests (at least by 30%) with 3 A s strategy (Awareness; Audit; Appropriateness) To reduce the number of useless examinations To avoid patient s exposure to ionising radiations To reduce waiting lists

26 Appropriateness in cardiology Very low even in Public health systems Very low even for risky and costly procedures Unavoidable in pay for volume systems Inappropriateness impacts on health, tax, environment. Hard to afford even for most affluent economies June 26, 2009 From Heartwire Cardiologist Gets 10 Years for Performing Unnecessary Interventions Michael O Riordan An interventional cardiologist from Louisiana, has been sentenced to 10 years in prison for performing unnecessary invasive interventional procedures and falsifying patient records.

27 Homer for President! Yes, we SCAN! The lessons of our Fathers: neglect costs, ignore doses, negate risks