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A systematic quality improvement initiative strongly improves appropriate use of coronary computed tomographic angiography (CTA) across a wide array of referring physician specialties, according to a new study published online August 8, 2012, ahead of print in the Journal of the American College of Cardiology.

Researchers led by Kavitha M. Chinnaiyan, MD, of William Beaumont Hospital (Royal Oak, MI), evaluated the efficacy of a continuous quality improvement initiative among 25,387 patients enrolled in the Advanced Cardiovascular Imaging Consortium (ACIC) at 47 hospitals in Michigan. The initiative included physician education emphasizing that loss of third-party payer coverage for CTA was possible if demonstrable improvement in appropriate use criteria could not be shown.

Major Improvements

Appropriate use increased and inappropriate use, uncertain scans, and unclassifiable scans were all reduced from the pre-quality initiative period (July 2007 to June 2008) through to follow-up (July 2010 to December 2010; table 1).

Table 1. Change in Appropriateness of CTA

^a P value compares pre-intervention with follow-up period.

Among inappropriate indications, CTA use in low-risk asymptomatic patients and high-risk symptomatic patients decreased from the pre-intervention period to follow-up (P < 0.0001 for both).

Referring physician information was available in 96.3% of patients, and all specialties—cardiology, internal medicine, emergency medicine, and other—showed improvements between pre-intervention and follow-up.

Compared to 2006, only 39.2% of scans remained in the same category with regard to appropriate use criteria. The bulk of this change came from the reclassification of 8,916 scans from “unclassifiable” in 2006 to “appropriate” in 2010.

Challenges to Widespread Implementation

The authors note that the study was limited by the lack of a control group including physicians who did not go through a quality improvement initiative; however, a variety of external factors most likely influenced the use of CTA over the course of the study.

In the present study, the threat of losing reimbursement was suggested but no particular threshold for appropriate testing was offered, Dr. Chinnaiyan told TCTMD in an e-mail communication. Another challenge to implementation is the need for continuous reassessment and feedback at each site, while in this initiative, these assessments only occurred quarterly.

The ACIC is only 1 of a number of quality improvement programs across varying specialties in the region, he noted, and the success of the CTA effort suggests collaborative partnerships between payers and physicians could result in similar successes elsewhere. Such a program is difficult to coordinate, as the ACIC includes a representative cross-section of centers including “academic and community hospitals (of various sizes), free-standing imaging centers, private physician offices . . . in both urban and rural areas,” Dr. Chinnaiyan explained.

“There are many challenges to instituting quality initiatives at such large scales in the real world,” Dr. Chinnaiyan said. “One is that physicians are busy taking care of patients, and do not necessarily have time to engage in such measures, unless they have a ‘stake’ in it. This is where the payer-physician collaborative partnerships can help.”

Chinnaiyan KM, Peyser P, Goraya T, et al. Impact of a continuous quality improvement initiative on appropriate use of coronary computed tomography angiography: Results from a multicenter, statewide registry, the Advanced Cardiovascular Imaging Consortium. J Am Coll Cardiol. 2012;Epub ahead of print.

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