Michael Poon (Lenox Hill Hospital-Northwell Health, New York, USA) discusses the progress made in treatment of cardiovascular disease, and considers how US healthcare practitioners can learn from their overseas colleagues in the use of coronary computed tomography angiogram (CTA), which he describes as the “gold standard” diagnostic technique in many countries.
As we lead into heart health month in February 2021, it’s important to reflect on the progress we’ve made in diagnosing and treating cardiovascular disease. Heart disease, according to the Centers for Disease Control and Prevention (CDC), is responsible for more than 600,000 deaths every year in the USA and nearly half of US adults have cardiovascular disease.
The impact of heart health issues and heart disease is far and wide reaching and a major priority in healthcare. Unfortunately, it’s quite difficult to change practice patterns which is evident in a new publication that I co-authored in the Journal of American College of Cardiology. The publication emphasised that even though traditional methods of diagnosing cardiovascular disease don’t yield promising results, they continue to be used because of perverse economic incentives. The SCOT-HEART and PROMISE trials highlighted the positive impact of a coronary CTA first approach in diagnosing and managing cardiovascular disease. By combining physiologic information from FFRCT with coronary CTA, clinicians can make decisions armed with powerful insights not available through other non-invasive pathways. Despite the benefits it presents, the US healthcare system is sorely behind its peers, specifically Japan and the UK, to establish CTA as the gold standard. So, how can we get up-to-speed?
To start, let’s outline what the traditional diagnostic pathway is—doctors will usually order a SPECT or stress test, which can determine if an artery in the heart is clogged or narrowed. The problem is that stress tests often miss blockages, or if a blockage is detected, it’s not always clear if it’s obstructing the blood flow. This means that if a patient’s symptoms persist, it will likely lead to a more invasive, costly approach. Despite these shortcomings, the challenges in making the switch to the CTA-first approach are crystalised by 2016 data showing “the US ratio of SPECT myocardial perfusion imaging to coronary CTA testing was 58:1” and by “perverse economic incentives, often rewarding the use of established, less effective practices as opposed to more innovative technologies offering improved medical outcomes with long-term cost reduction.”
The recommendations also point out that this imbalance is perpetuated in the USA today even as data from ISCHEMIA, SCOT-HEART, and PROMISE demonstrate the clear benefits to patients of a CTA-first pathway. Physicians and clinical societies outside of the USA have already implemented programmes, guidelines, and education to enable and promulgate a switch to CTA-first testing and adoption of FFRCT when indicated, and the recommendations include a call for “Collaboration among UK, US, and European advisory boards [to] enhance learning and accelerate US adoption.”
In the spirit of heart health, it’s crucial to overcome these challenges and better serve patients. To evolve the US approach, we need to focus on three key areas:
- Creating Easier Access. Some of the important work here will include increasing local provider expertise and competencies, allowing practicing cardiologists to become certified in coronary CTA, and eliminating insurance pre-authorisations for both CTA and FFRCT which hinder providers from choosing a better clinical path for their patients.
- Improve Education. Providers, such as cardiology fellows and CT technologists, need more training and established quality assessments, while practicing cardiologists and primary care physicians need to know (1) for which patients they should consider coronary CTA and (2) how to use the findings in patient management.
- Address Financial Hurdles. The US healthcare system requires changes to more accurately reflect the value and true costs of coronary CTA and FFRCT. This must include meaningful increases to CMS payment for this preferred pathway, as CMS reimbursement has decreased by 36% for coronary CTA and 34% for FFRCT over the past four years. Additionally, we as physicians must continue to engage with payers to fix financial imbalances driven by both geographic and site-of-service (hospital vs non-hospital) inconsistencies.
From a physician and health system perspective, the impact this technology can make is powerful as heart disease costs the country US$219 billion each year and one in six healthcare dollars is spent on cardiovascular disease. In HeartFlow’s PLATFORM trial, which compared standardised diagnostic strategies to the HeartFlow Analysis, a non-invasive cardiac test that leverages deep learning to create a personalised 3D model of the heart, found that across 584 patients, there was an 83% reduction in unnecessary invasive angiograms and none of those patients had an adverse reaction. Furthermore, the use of the HeartFlow Analysis resulted in 33% savings for health systems which breaks down to US$4,000 per patient after one year. If we consider the impact at a large-scale, this could reduce overall spending and the residual cost and labor due to diagnostic complications.
The evidence and the desire are present today for a more innovative approach to be put in place within health systems. Through collaboration and education, we can make a permanent change that allows for an evolved treatment pathway that improves patient outcomes and provider insights alike.