Abstract
Background: Non-invasive Cardiovascular imaging (NICI), including cardiovascular magnetic resonance (CMR) imaging provides important information to guide the management of patients with cardiovascular conditions. Current rates of NICI use and potential policy determinants in the United States of America (US) and England remain unexplored.Methods: We compared NICI activity in the US (Medicare fee-for-service, 2011–2015) and England (National Health Service, 2012–2016). We reviewed recommendations related to CMR from Clinical Practice Guidelines, Appropriate Use Criteria (AUC), and Choosing Wisely. We then categorized recommendations according to whether CMR was the only recommended NICI technique (substitutable indications). Reimbursement policies in both settings were systematically collated and reviewed using publicly available information.Results: The 2015 rate of NICI activity in the US was 3.1 times higher than in England (31,055 vs. 9,916 per 100,000 beneficiaries). The proportion of CMR of all NICI was small in both jurisdictions, but nuclear cardiac imaging was more frequent in the US in absolute and relative terms. American and European CPGs were similar, both in terms of number of recommendations and proportions of indications where CMR was not the only recommended NICI technique (substitutable indications). Reimbursement schemes for NICI activity differed for physicians and hospitals between the two settings.Conclusions: Fee-for-service physician compensation in the US for NICI may contribute to higher NICI activity compared to England where physicians are salaried. Reimbursement arrangements for the performance of the test may contribute to the higher proportion of nuclear cardiac imaging out of the total NICI activity. Differences in CPG recommendations appear not to explain the variation in NICI activity between the US and England.
Highlights
Many patients with suspected or known cardiovascular diseases benefit from non-invasive cardiovascular imaging (NICI) to help reach correct diagnoses, to risk stratify and to guide clinical management
Blinded to the categories of whether modalities were substitutable for indications, a cardiologist (AK) independently retrospectively categorized consecutive June 2018 cardiovascular magnetic resonance (CMR) reports from one large academic center in the United States (US) (Hospitals of the University of PennsylvaniaPenn Presbyterian) and one in England (Barts Health National Health Service (NHS) Trust) according to the indication from any of the Clinical practice guidelines (CPGs) and appropriate use criteria (AUC)
Interpretation: Our findings suggest that clinical practice between the US and England in this CMR two-academic-center pilot may not differ with regards to the frequency of CMR use for recommended indications that did not favor one NICI technique over another
Summary
Many patients with suspected or known cardiovascular diseases benefit from non-invasive cardiovascular imaging (NICI) to help reach correct diagnoses, to risk stratify and to guide clinical management. Nuclear cardiac imaging and echocardiography have been long established, but more recently cardiovascular magnetic resonance (CMR) and cardiac computed tomography (CT) have become available to broaden the options available to cardiologists when considering the best investigations for their patients. The United States (US) is often considered to provide insufficient clinical CMR activity compared to other tests, in particular to nuclear cardiac imaging [1]. Evidence to support these claims is currently lacking, recent trends in NICI use are largely unknown, and there is likely substantial geographical variation in NICI activities. Non-invasive Cardiovascular imaging (NICI), including cardiovascular magnetic resonance (CMR) imaging provides important information to guide the management of patients with cardiovascular conditions. Current rates of NICI use and potential policy determinants in the United States of America (US) and England remain unexplored
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