Setting: Outpatient
Numerator: Patients having a low-risk surgery (i.e., endoscopic procedure, superficial procedure, cataract surgery, breast biopsy) preceded, within 30 days, by a single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), Stress Echocardiography, or Stress magnetic resonance imaging (MRI) study
Denominator: Patients having a low-risk surgery (i.e., endoscopic procedure, superficial procedure, cataract surgery, breast biopsy)

A review of stress echocardiography appropriateness criteria for specific clinical scenarios was recently completed and published by The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE). Review of SPECT MPI appropriateness criteria for specific clinical scenarios was completed and published by ACCF and the American Society of Nuclear Cardiology (ASNC). The purpose of the published criteria is to "help guide a more efficient and equitable allocation of health care resources."

The proposed measure seeks to calculate relative use of stress echocardiography, stress MRI, and SPECT MPI prior to low-risk non-cardiac surgical procedures.

The appropriateness criteria provided specific guidance that use of stress echocardiography and SPECT MPI are not appropriate tests for preoperative evaluation of patients undergoing low risk non-cardiac surgical procedures. The appropriateness score assigned to the use of stress echocardiography and SPECT MPI for the indication is the lowest at one (1). Scores of 1-3 are defined as inappropriate (the test is generally not indicated).

The criteria define low risk surgery as cardiac death or MI in less than 1 percent of performed procedures — endoscopic procedures, superficial procedures, cataract surgery, and breast surgery (biopsy).

Application of the appropriateness criteria was recently conducted by an academic medical center. The study concluded that 18 percent of stress echocardiography procedures were performed for inappropriate reasons. Specific to preoperative evaluation for non-cardiac surgical procedures, 31 percent (19 of 61) of stress echocardiograms performed were inappropriate based upon established appropriateness criteria.

The study also concluded fourteen percent (14%) of SPECT MPI studies were performed for inappropriate reasons. Specific to preoperative evaluation for non-cardiac surgical procedures, thirty-eight percent (6 of 16) of SPECT studies performed were inappropriate based upon the criteria.

The measure follows appropriateness criteria for stress echocardiography and SPECT MPI published by the Journal of the American College of Cardiology. The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE), together with other specialty groups, reviewed the scenarios associated with the use of stress echocardiography. Similarly, ACCF and The American Society of Nuclear Cardiology (ASNC) reviewed clinical scenarios associated with the use of SPECT MPI. Scenarios were scored from 1 through 9. Scores in the range of 1 though 3 implied the test is generally not indicated. The score assigned to the clinical scenario of the proposed measure was 1 (one) for both stress echocardiography and SPECT MPI.

Limited information was found after conducting an environmental scan in the area of usability; however, the experience in one academic setting suggests that the measure is eminently usable. Stress echocardiography, stress MRI, and SPECT MPI are procedures that must be ordered by a physician to be performed. Therefore, there is the distinct opportunity for the physician not to order the unnecessary study and for the rendering physician to ensure that an unneeded study is not performed (controllability).

This measure may be applied to any setting in which these studies are performed; however, the focus of the measure is the outpatient setting. The intended audience (health care providers) will easily understand the results and find them useful in decision-making. The health care provider can use the results to reduce costs without compromising quality of care.

There are few measures that address imaging efficiency that have been developed despite the recent tremendous growth in imaging in the United States. There are no closely related existing measures.

We anticipate constructing this measure using Medicare claims files. The specifications are anticipated to be readily applied to Medicare claims data to determine the use of stress echocardiography, SPECT MPI, and Stress MRI for preoperative evaluation. As the measure will be claims-based and no 'right' number can be set in advance, data will be gathered and analyzed to identify outlier facility practices in this area.

Appropriate codes must be documented to assure that the population and studies are properly identified. We can expect some minimal distortion in the results due to imprecise coding.

To implement the measure, patient-identifying information is used to link the procedure to antecedent claims or diagnostic claims. After this link has been determined and the numerators and denominators for the measure have been counted, the patient-identifying information is eliminated from the file. The reporting of the measures is at an aggregate level that does not indicate any claim or person-level detail in compliance with HIPAA requirements.

The anticipated unit of measurement is the outpatient facility; however, the measure may be applicable to other settings.