RESUMO
The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1-9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.
Assuntos
Cardiologia/normas , Angiografia Coronária/normas , Isquemia Miocárdica/terapia , Adulto , Idoso , Algoritmos , American Heart Association , Tomada de Decisões , Exercício Físico , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Segurança do Paciente , Medição de Risco , Sociedades Médicas , Resultado do Tratamento , Estados UnidosAssuntos
Comitês Consultivos/normas , American Heart Association , Cardiologia/normas , Isquemia Miocárdica/diagnóstico , Sociedades Médicas/normas , Angiografia/normas , Ecocardiografia/normas , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Imagem Cinética por Ressonância Magnética/normas , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/terapia , Medição de Risco , Procedimentos Cirúrgicos Torácicos/normas , Tomografia Computadorizada por Raios X/normas , Estados Unidos/epidemiologiaAssuntos
Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Hipertensão/diagnóstico , Hipertensão/terapia , Indicadores de Qualidade em Assistência à Saúde/normas , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/fisiopatologia , Humanos , Hipertensão/complicações , Hipertensão/fisiopatologia , Adesão à Medicação , Avaliação de Resultados em Cuidados de Saúde , Pacientes Ambulatoriais , Inibidores da Agregação Plaquetária , Abandono do Hábito de Fumar , Estados UnidosAssuntos
Envelhecimento , Competência Clínica , Cognição , Médicos , Disfunção Cognitiva/diagnóstico , Humanos , Inabilitação do MédicoAssuntos
Ética Profissional , Cardiologia , Ensaios Clínicos como Assunto/ética , Ensaios Clínicos como Assunto/normas , Códigos de Ética , Conflito de Interesses , Ética Médica , Prova Pericial , Hospitais/normas , Experimentação Humana/ética , Experimentação Humana/normas , Humanos , Marketing de Serviços de Saúde , Prática Profissional , Pesquisadores , Apoio à Pesquisa como Assunto , Revelação da VerdadeAssuntos
Comitês Consultivos , Doenças Cardiovasculares/terapia , Conflito de Interesses , Ética Médica , Autorreferência Médica/ética , Sociedades Médicas , Competência Clínica/legislação & jurisprudência , Conflito de Interesses/legislação & jurisprudência , Hospitais Especializados/ética , Hospitais Especializados/legislação & jurisprudência , Humanos , Autorreferência Médica/legislação & jurisprudência , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde/ética , Garantia da Qualidade dos Cuidados de Saúde/legislação & jurisprudência , Estados UnidosRESUMO
The rapid development and clinical deployment of CT angiography raises several important issues, including assurance of professional competence and technical quality, self-referral, the relative role of radiologists and cardiologists, appropriateness and proper indications, the detection and disposition of unexpected or incidental findings and the concern for the rapidly increasing costs of health care and imaging. These questions are properly addressed within the framework of medical ethics, including principles of beneficence, autonomy and justice.
Assuntos
Angiografia Coronária/ética , Doença das Coronárias/diagnóstico por imagem , Ética Médica , Tomografia Computadorizada por Raios X/ética , Publicidade/ética , Competência Clínica , Angiografia Coronária/economia , Humanos , Achados Incidentais , Papel do Médico , Encaminhamento e Consulta/ética , Tomografia Computadorizada por Raios X/economiaAssuntos
Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Hipertensão/diagnóstico , Hipertensão/terapia , Indicadores de Qualidade em Assistência à Saúde/normas , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/fisiopatologia , Humanos , Hipertensão/complicações , Hipertensão/fisiopatologia , Adesão à Medicação , Avaliação de Resultados em Cuidados de Saúde , Pacientes Ambulatoriais , Inibidores da Agregação Plaquetária , Abandono do Hábito de Fumar , Estados UnidosRESUMO
Under the auspices of the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC), an appropriateness review was conducted for radionuclide cardiovascular imaging (RNI), specifically gated single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). The review assessed the risks and benefits of the imaging test for several indications or clinical scenarios and scored them based on a scale of 1 to 9, where the upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The mid range (4 to 6) implies that the test may be generally acceptable and may be a reasonable approach for the indication. The indications for this review were primarily drawn from existing clinical practice guidelines and modified based on discussion by the ACCF Appropriateness Criteria Working Group and the Technical Panel members who rated the indications. The method for this review was based on the RAND/UCLA approach for evaluating appropriateness, which blends scientific evidence and practice experience. A modified Delphi technique was used to obtain first- and second-round ratings of 52 clinical indications. The ratings were done by a Technical Panel with diverse membership, including nuclear cardiologists, referring physicians (including an echocardiographer), health services researchers, and a payer (chief medical officer). These results are expected to have a significant impact on physician decision making and performance, reimbursement policy, and future research directions. Periodic assessment and updating of criteria will be undertaken as needed.
Assuntos
Circulação Coronária , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/fisiopatologia , Tomografia Computadorizada de Emissão de Fóton Único/normas , HumanosRESUMO
BACKGROUND: Practice-based learning and improvement (PBLI) is 1 of 6 general competencies expected of physicians who graduate from an accredited residency education program in the United States and is an anticipated requirement for those who wish to maintain certification by the member boards of the American Board of Medical Specialties. This article describes methods used to assess PBLI. SUMMARY: Six electronic databases were searched using several search terms pertaining to PBLI. The review indicated that 4 assessment methods have been used to assess some or all steps of PBLI: portfolios, projects, patient record and chart review, and performance ratings. Each method is described, examples of application are provided, and validity, reliability, and feasibility characteristics are discussed. CONCLUSION: Portfolios may be the most useful approach to assess residents' PBLI abilities. Active participation in peer-driven performance improvement initiatives may be a valuable approach to confirm practicing physician involvement in PBLI.