A case-based ethics discussion

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ORIGINAL ARTICLE How to approach an inappropriately ordered myocardial perfusion stress study: A case-based ethics discussion Ajay V. Srivastava, MD,a Andrew Kontak, MD,b Leslee J. Shaw, PhD,c,d Neal W. Dickert Jr., MD, PhD,c,e,f Vasken Dilsizian, MD,g Sharmila Dorbala, MBBS,h Jamshid Shirani, MD,i and Andrew J. Einstein, MD, PhDb,j a

Division of Cardiology, Heart and Vascular Institute, Scripps Clinic Torrey Pines, La Jolla, CA Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY c Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA d Emory Clinical Cardiovascular Research Institute, Atlanta, GA e Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA f Atlanta VA Medical Center, Decatur, GA g Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD h Noninvasive Cardiovascular Imaging Program, Departments of Radiology and Medicine (Cardiology), Brigham and Women’s Hospital, Boston, MA i Department of Cardiology, St. Luke’s University Health Network, Bethlehem, PA j Department of Radiology, Columbia University Medical Center, New York, NY b

Received Jun 16, 2015; accepted Jun 16, 2015 doi:10.1007/s12350-015-0231-3

CASE PRESENTATION A 38-year-old woman visited her primary care physician (PCP) for a routine office visit related to a recent diagnosis of hypertension. During the visit, she mentioned some left-sided chest discomfort mostly occurring during her evening walks, but also occasionally associated with stress at work. She described the pain as a burning sensation and each episode lasted for 2 to 3 minutes. She denied associated symptoms. Her last episode of chest discomfort was 10 days prior to her PCP visit while taking her dog for walk but she did not seek any medical help as it resolved spontaneously. She has no prior history of coronary artery disease and has never had a stress test before. Her past medical history is Presented at the American Society of Nuclear Cardiology 18th Annual Scientific Sessions, Boston, MA, September 19, 2014. Reprint requests: Ajay V. Srivastava MD, Division of Cardiology, Heart and Vascular Institute, Scripps Clinic Torrey Pines, La Jolla, CA, 92037; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2015 American Society of Nuclear Cardiology.

primarily significant for newly diagnosed hypertension, for which she takes hydrochlorothiazide 25 mg one tab once daily. Her family history is notable for hypertension but no history of heart failure, myocardial infarction, or stroke. She denies tobacco, alcohol, or illicit drug use. She works as a school teacher and walks for about 20 minutes 2 to 3 times/week. On examination, blood pressure was 140/84 mmHg, pulse 82 beats per minute with a body mass index of 27 kg/m2. Her cardiac exam is significant for normal heart sounds with no signs of heart failure. A 12-lead ECG performed showed normal sinus rhythm with no evidence of ischemia or prior myocardial infarction. Worried about the risk of coronary artery disease, her PCP tells her about the hospital having a new ‘‘Fantastic state of the art PET/CT camera system and that she should definitely check it out.’’ Subsequently, she underwent a rubidium-82 regadenoson vasodilator stress myocardial PET/CT study. As shown below (Figure 1), the test was negative for flow-limiting coronary artery disease. Upon obtaining the normal stress test results, the ordering primary care provider seeks your opinion on

Srivastava et al A case-based ethics discussion

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Figure 1. Stress-rest Rb-82 pharmacologic vasodilator PET/CT myocardial perfusion images.

how best to interpret the results of the scan and the overall role of myocardial PET/CT using vasodilator stress agents, as opposed to traditional treadmill exercise. DISCUSSION The Best Strategy When Faced with an Inappropriately Ordered Test The major subject of discussion from this case is twofold: First, how should an interpreting physician

approach an inappropriately ordered nuclear stress test and second, should the interpreting physician get personally involved in the decision-making process between the ordering provider and patient when it comes to choosing the right stress test. Stress testing in women (comments by Dr. Leslee Shaw). It is our responsibility, along with the ordering physician, to make sure the appropriate study is ordered for a given patient and to practice evidencebased medicine. The patient in the above clinical scenario has a low Framingham risk score despite her

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history of hypertension. We know from the WOMEN trial1 that in low-risk, exercising women, a diagnostic strategy using exercise treadmill testing (ETT) yielded similar 2-year post-test outcomes compared to myocardial perfusion imaging and provided significant diagnostic cost savings. In such patients, ETT with selective follow-up testing should be considered as the initial diagnostic strategy in symptomatic women with suspected coronary artery disease. Performing an ETT in our patient would not only help in evaluating for ischemia but would also give valuable information regarding whether her symptoms could be replicated during treadmill exercise and shed light on her functional capacity. Patient-provider shared decision making when ordering a diagnostic test (comments by Dr. Neal Dickert). This case is a nice example of the role of shared decision making. The test ordered is not the right test and makes you wonder what the discussion was at the time of the office visit. Often we know those conversations happen in very abbreviated forms and do not involve any discussion of radiation risk2,3 or alternative modalities of testing. In that context, there is no avoiding the fact there is a role for interpreting physicians to help decide the right test. It is important to keep in mind also, just because someone orders a test one way, does not mean it has to be done that way. There is a role for communicating with the provider as well as communicating with the patient once they are there in your stress lab. Challenge for interpreting physicians (comments by Dr. Vasken Dilsizian). Interpreting physicians are faced with ethical and real world logistical challenges. In reality, most of us do not have the luxury of a detailed history, as was provided in the first two paragraphs of this case report. As interpreting physicians, it is not uncommon for the clinical history to comprise a symptom and a risk factor, such as chest pain and hypertension. Without additional detailed history, it is extremely difficult, if not impossible, for the interpreting physician to second guess the referring physician, and change the test to a regular treadmill study. On top of that, to contact the referring physician, who is seeing patients every 15 minutes and to ask for clarifying details on the history, would also be frustrating. Most referring physicians will not be able to recollect the specific details about a patient, particularly regarding the choice of pharmacologic myocardial perfusion study instead of regular treadmill study without perfusion imaging. Although this is a nice ethical discussion, the reality is, it is difficult to implement these changes the same day of the scheduled test.

Srivastava et al A case-based ethics discussion

Utility and challenge of prescreening ordered stress tests prior to patient arrival (comments by Dr. Sharmila Dorbala). There is no doubt this is a very challenging area for any imaging physician to address. Cardiovascular imaging has become fairly complex. Choosing a suitable test from many possible options may be tough for referring providers who may not be imaging experts. At our institution, imaging fellows, prescreen (‘‘protocol’’) the SPECT and PET orders, by reviewing the electronic medical records and if needed contacting the referring provider. Studies are ‘‘protocoled’’ on an ongoing basis, daily, from as early as 1 week in advance all the way up until the day of the test (for inpatient studies). When a requested test is apparently not the best possible option, the referring provider is contacted to select the optimal test to help answer the clinical question and guide management. However, if the originally scheduled order is changed, pre-authorization for a new test may not be possible on short notice. Also, some patients are inconvenienced by taking time off from work; others may have traveled from out of town to undergo the prespecified ‘‘special’’ test. For each of these reasons, it is particularly important to prescreen the request as far in advance of the test date as possible. In future, with novel online decision support systems, this prescreening process may occur at the time the test is ordered, and only a few studies may require a phone conversation with the referring provider. It is the responsibility of the interpreting physician to reduce inappropriately ordered/ performed stress tests (comments by Neal Dickert Jr. and Dr. Leslee Shaw). There is clearly a red flag with this case and makes one wonder if there is a system which could identify appropriateness upfront when tests are being ordered. If it is not the imaging physician’s role to change it themselves, a systemic fix is needed to prevent this order from being requested in the first place. A solution is possible on multiple levels and as evidenced by this case, clearly something needs to be done differently. From a larger healthcare system viewpoint, the Centers for Medicare and Medicaid Services (CMS) plans to evaluate physicians by appropriate use criteria (AUC).4 Before it is too late, imaging physicians still have time figure out a strategy to keep ‘‘rarely appropriate’’ studies requests out of their nuclear lab. On another note, it is worth mentioning the referring physician’s misplaced opinion of what the value is of the new ‘‘bell and whistle’’ you have in your lab and what your response should be when asked how it should be used. There has to be ongoing education so that referring physicians understand the AUC, at least on a global

Srivastava et al A case-based ethics discussion

basis. Finding a solution may be different from one institution to the next and specific challenges come up based on the wide ranging knowledge base of the referring physicians, but it is something that should be addressed. Can we have a systemic fix that would reduce inappropriately stress tests? (comments by Dr. Jamshid Shirani and audience comments). Is it advised the ordering physician utilize the AUC. At some institutions, the electronic ordering system itself employs imbedded AUC algorithms. Other labs include hyperlinks with examples of clinical scenarios to help risk stratify patients from the beginning. If at the end you still insist on having a special test done for any reason, it is prudent to call the imaging physician to be able to do it. As imaging readers, our role is also as ‘‘imaging consultants.’’ Being trained across multiple imaging modalities, we are in a good position to educate the referring physician on an appropriate test for their patient. On the other hand, if there is too much resistance to order a certain test, a consequence might be an increase in ordering of a competing test, which for a nuclear cardiologist may be a coronary CT angiogram performed by a different department. This is an additional ethical problem we face, since imaging physicians base their productivity on RVUs and are expected to grow their practice and increase the number of tests done. There is no single method to reduce the number of inappropriate tests, rather a multi-pronged approach should be used, including (a) utilization of electronic medical records for risk stratification based on patient history and risk factors, (b) applying AUC guidelines, including imbedding instructions and placing stopgaps within the order to prevent inappropriate tests from the beginning, and (c) imaging physicians should act as consultants to referring physicians by educating them and providing constructive feedback on test ordering when needed. CONCLUSION Making sure an appropriate test is ordered for each patient is a responsibility of everyone involved, from the referring physician, who may not be versed in the appropriateness criteria or knowledgeable of all the

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stress modalities available to the imaging cardiologist, who is the expert. As caretakers of the stress testing lab, it our responsibility to have a system in place to screen for inappropriately ordered tests prior to patient arrival. There are multiple applications available to help identify inappropriately ordered studies, ranging from electronic medical records to expert guideline documents like the AUC, but perhaps most important to an individual laboratory is direct communication with referring providers. By utilizing such applications, there is great potential to decrease the number of inappropriate tests ordered, with such downstream benefits as reduced radiation and cutting down on redundant costs to the healthcare system. Our patient is not the first and will not be the last inappropriate referral. As imaging physicians, it is our moral obligation to prevent this trend and with perseverance, a systemic fix is attainable. Acknowledgment The authors thank Jane Dunne for assistance in organizing the ethics session.

References 1. Shaw LJ, Mieres JH, Hendel RH, Boden WE, Gulati M, Veledar E, et al. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Circulation 2011;124:123949. 2. Cerqueira MD, Allman KC, Ficaro EP, Hansen CL, Nichols KJ, Thompson RC, et al. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010;17:709-18. 3. Fazel R, Gerber TC, Balter S, Brenner DJ, Carr JJ, Cerqueira MD, et al. Approaches to enhancing radiation safety in cardiovascular imaging. A scientific statement from the American Heart Association. Circulation 2014;130:1730-48. 4. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/ SNM 2009 appropriate use criteria for cardiac radionuclide imaging: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201-29.