3. About the Cardiac Services Clinical Committee

The Cardiac Services Clinical Committee (the Committee) is part of the second tranche of Clinical Committees. It was established in April 2016 to make recommendations to the Taskforce on MBS items within its remit, based on rapid evidence review and clinical expertise. The Taskforce asked the Committee to review cardiac-related MBS items.

The Committee consists of 18 members, whose names, positions/organisations and declared conflicts of interest are listed in Section 3.1. All members of the Taskforce, Clinical Committees and Working Groups were asked to declare any conflicts of interest at the start of their involvement and are reminded to update their declarations periodically.

3.1 Committee members

Table 1. Committee members and declared conflicts of interest
Name Position/Organisation Declared conflict
Professor Richard Harper (Chair) Emeritus Director of Cardiology, Monash Medical Centre Adjunct Professor of Medicine, Monash University None
Associate Professor Aidan Foy General Physician and Gastroenterologist Clinical Dean Maitland Clinical School University of Newcastle and University of New England Joint Medical Program. None
Associate Professor Andrew MacIsaac Director of Cardiology Services and Deputy Chief Medical Officer, St Vincent’s Hospital, Melbourne Immediate past president, Cardiac Society of Australia and New Zealand None
Professor Andrew McGavigan Professor of Cardiology, Flinders University; Director of Arrhythmia Services, Flinders Medical Centre, South Australia; Chair EP and Pacing Council, CSANZ. None
Dr Daniel Moses Director of Medical Imaging, Northern Hospital Network, South Eastern Sydney Local Health District. Conjoint Senior Lecturer, Faculty of Medicine, University of New South Wales None
Associate Professor David Muller Director of Cardiac Catheterisation Laboratories, St Vincent’s Hospital, Sydney Associate Professor of Medicine, University of New South Wales None
Professor Derek Chew Professor of Cardiology, Flinders University Regional Director of Cardiology, Southern Adelaide Local Health Network None
Associate Professor Gary Sholler Director Cardiac Services, Sydney Children’s Hospitals Network None
Associate Professor Glenn Young Senior Clinical Lecturer, University of Adelaide; Electrophysiologist, Adelaide Cardiology None
Associate Professor Ian Scott Director, Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital School of Medicine, University of Queensland None
Associate Professor Jayme Bennetts Department of Surgery, Flinders University Director, Cardiac and Thoracic Surgery, Flinders Medical Centre Chair, Government Relations, Australian and New Zealand Society of Cardiac and Thoracic Surgeons. None
Associate Professor John Atherton Director of Cardiology, Royal Brisbane and Women’s Hospital Associate Professor, Department of Medicine, University of Queensland None
Ms Karen Carey Member, National Health and Medical Research Council (NHMRC), and Chair, Community and Consumer Advisory Group None
Professor Mark Harris Director, Centre of Obesity Management and Prevention Research Excellence in Primary Health Care (COMPaRE – PHC); Foundation Professor of General Practice and Executive Director, Centre for Primary Health Care and Equity, University of New South Wales. None
Professor Paul Bannon Head of Department, Cardiothoracic Unit, The Royal Prince Alfred Hospital Professorial Chair of Cardiothoracic Surgery, University of Sydney President, Australian and New Zealand Society of Cardiac and Thoracic Surgeons None
Dr Ruth Arnold Cardiologist, Orange Health Service Chair, Rural Working Party, Cardiology, Agency for Clinical Innovation, New South Wales None
Professor Tom Marwick Director, Baker IDI Heart & Diabetes Institute None
Professor Michael Besser (Taskforce Ex-Officio) Associate Professor, Sydney University Consultant Emeritus Neurosurgeon, Royal Prince Alfred Hospital and the Children's Hospital Westmead None

It is noted that the majority of Committee members share a common conflict of interest in reviewing items that are a source of revenue for them (i.e., Committee members claim the items under review). This conflict is inherent in a clinician-led process, and having been acknowledged by the Committee and the Taskforce, it was agreed that this should not prevent a clinician from participating in the Review and is not noted in the table above.

3.2 Areas of responsibility of the Committee

The Committee was assigned 188 MBS items to review, covering procedures, investigations and other services related to cardiology. Appendix C contains a list of items reviewed by the Committee. In the 2014/15 financial year (FY), these items accounted for approximately 5.3 million services and $647 million in benefits. Over the past five years, service volumes for these items have grown at 6.8 per cent per year, and the cost of benefits has increased by 7.6 per cent per year. This growth is largely explained by a 5.5 per cent increase per year in the number of services per capita (Figure 2).

Figure 2: Drivers of growth
Figure 2 is a graph that shows the increase in percentage for each of the drivers of growth from 2009-10 to 2014-15. The total benefits increased at 7.6%, due to a 6.8% increase on the number of services and 0.7% increase on the average benefits per service. The increase on the number of services was due to a 1.3% increase on the population and the 5.5% increase on services per 100,000.

Unpublished data, extract based on date of service data from 2009-10 to 2014-15 which uses data processed up to 30 May 2016. (Department of Health).

3.3 Summary of the Committee’s review approach

The Committee completed a review of its items across seven full Committee meetings, during which it developed the recommendations and rationales outlined in Sections 4 – 9.

The Review drew on various types of MBS data, including data on utilisation of items (services, benefits, patients, providers and growth rates); service provision (type of provider, geography of service provision); patients (demographics and services per patient); co-claiming or episodes of services (same-day claiming and claiming with specific items over time); and additional provider and patient-level data, when required. The Review also drew on data presented in the relevant literature and clinical guidelines, all of which are referenced in the report. Guidelines and literature were sourced from medical journals and other sources, such as professional societies.

3.3.1 Structure of the report

The Committee reviewed 188 items and made recommendations based on the best available evidence and clinical expertise, in consultation with relevant stakeholders. The Committee’s most important provisional recommendations for stakeholder consultation relate to the investigation and management of coronary artery disease (CAD), which includes the restructuring of invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI) items, along with a suite of changes to cardiac imaging and stress-testing items. There has also been significant restructuring of the cardiac surgical items, along with a number other changes, to improve the value of the services more broadly. Other minor changes and the removal of obsolete items have been recommended to simplify and modernise the MBS. The changes focus on the objectives of the MBS Review: to improve access to medical services, encourage best practice, increase value to consumers and the health system, and simplify the MBS to improve patient care.

An inclusive set of stakeholders is now engaged in consultation on the recommendations resulting from this process, which are outlined in this report. Following this period of consultation, the Committee will consider stakeholder feedback before finalising the recommendations and presenting them to the Taskforce. The Taskforce will consider the report and stakeholder feedback before making recommendations to the Minister for Health for consideration by the Government.

3.3.2 Working group structure

Due to the volume and complexity of the items in scope, the Committee formed five Working Groups with broader membership to provide greater content expertise. The recommendations in this report are organised by Working Group, with order determined by both priority and logical flow, as many of the items and recommendations are interconnected.

3.3.3 Numbering of proposed items

Throughout the report, the Committee recommends new or substantially changed items, several of which involve splitting or consolidating current items. These proposed items are often referred to using letters to differentiate them for ease of reference. If the recommended items are ultimately added to the MBS, the Department of Human Services (DHS) will assign new numbers in the usual format. The Committee is not recommending changes to the MBS numbering system.

3.3.4 Diagnostic imaging items with “NK” designations

The majority of diagnostic imaging items on the MBS are duplicated, with a designation of “K” for those performed on newer equipment or “NK” for those performed on older equipment. The Committee did not feel that the use of older equipment should be specifically excluded for any of the services reviewed, and for this reason only the “K” versions are listed below. All endorsed recommendations are expected to apply to “NK” equivalents without modification. For example, it is recommended that all echocardiogram recordings be made on digital media, and that older equipment unable to record digitally should not be used for MBS-rebated services. However, the “NK” items for echocardiography may be retained as digital equipment will age over time and cease to be eligible for “K” items.

3.3.5 Other MBS item attributes

Items on the MBS are attributed with markers such as (Anaes.) or (Assist.) to identify when additional services are claimable, or to apply other rules of the MBS. Unless specifically mentioned, the Committee has not recommended any changes to these attributes.

3.3.6 Implementation and compliance

The MBS descriptors proposed in this report reflect aspects of ideal clinical care supported by national and international guidelines, appropriateness criteria and expert opinion. The Committee recognises that good clinical care often requires some individualisation in order to meet the specific needs of the patient.

Many current MBS items describe services, but not the appropriate indications for use. In addition to implementing an ongoing review process (as described in Section 5.1), the Committee recommends that the approach to compliance and audit be reviewed, particularly with regard to qualitative and clinical descriptor parameters. MBS compliance has provided input throughout the drafting process to ensure the proposed descriptors are clear and auditable. For example instead of generally referring to ‘guidelines’, where possible the relevant information has been extracted from the current guidelines and incorporated into the descriptor or explanatory note. As mentioned above, this necessitates a robust ongoing review process as recommended by the Committee in Section 5.1.

In light of the substantially more detailed descriptors, it is important to ensure that compliance efforts remain directed at aspects of care that are clearly deemed inappropriate, while also applying behavioural economics techniques to ensure the desired behaviour changes are realised and sustained. It is important that the compliance function continue to work with the profession to achieve this, and the Committee agrees that cardiologists would welcome the opportunity to be involved in compliance efforts to ensure that the MBS is used to provide high value care.

The Committee acknowledges that the recommendations in this report will necessitate changes for the health system, providers and patients, some of which will be significant. Whether implemented gradually or as a ‘big bang’, there will be challenges. The complexity of the implementation phase should not be understated and implementation planning should be a high priority to minimise confusion, facilitate a smooth transition and maximise the impact captured from the recommendations.

3.4 Consumer impacts summary

The Committee brought together practitioners with experience in and commitment to the care of people with cardiac conditions in order to examine how well the descriptions of Medicare items match current clinical practice and meet the needs of Australians. Consumer representatives were on the Committee and every Working Group.

This section provides a more detailed discussion of the consumer impacts of the recommendations in this report, using the consumer representative framework. A list of the recommendations, written in plain English, can be found in Appendix A – Summary for consumers.

3.4.1 Consumer representative framework

  • ΔChanges have been recommended for some items that are no longer up to date. Some items are no longer used, and some should not be used because clinical best practice has changed since they were originally described. These items have been recommended for deletion.
  • ΔThe majority of the work conducted by the Committee focused on clinical issues and the provision of clinical services. As a result, the consumer representative relied frequently upon the advice of the clinicians regarding how consumers would be affected.

The consumer representative used the following framework to assess recommendations.

  1. Where no changes to an MBS Item were recommended, there was no consideration of consumer issues.
  2. Where changes or the deletion of MBS Items were recommended, the consumer representative considered the following questions:
    1. Would there be a positive or negative impact on safety?
    2. Would there be a positive or negative impact on the quality of services provided?
    3. Would there be any limitations on access, particularly for people living in rural and remote locations or people with special needs, including Indigenous Australians?
    4. Would the efficacy of the test or treatment (or sometimes a series of tests or treatments) be reduced or increased?
    5. Would the changes reduce or increase cost-effectiveness or future costs, and was there the potential for a perverse outcome?
    6. Would the change increase accountability by providing conditions against which service providers could be measured?
    7. Would the change increase data collection for research, monitoring and audit purposes?

3.4.2 Cardiac services outcomes

During the review of cardiac services, clinician expert opinion was relied upon in several instances where the research did not demonstrate a clear position. In some instances, there was disagreement between clinicians. In general, the consumer issues were resolved as follows:

Safety

  • ΔThe safety of cardiac services was not negatively affected by any of the recommendations.

Quality

  • ΔMany of the recommended changes seek to improve quality, primarily by aligning the reimbursement system with evidence-based practice. None of the recommendations negatively affected the quality of cardiac services, but it is important to note that in some instances, rural or remote populations and/or Indigenous Australians have poorer access to quality care than populations in cities (e.g., diagnostic equipment is older and may produce lower quality images with higher radiation levels).
  • ΔIt is difficult to achieve the right balance in such instances, because many people prefer to receive services close to their home—even if local services are of an inferior quality—rather than travelling to a major centre for treatment. In general, where there was a health outcome effect, the Committee felt that people should travel to receive evidence-based care.

Access

  • ΔAppropriate access was not negatively affected, although existing issues facing rural areas persist (described above). It was also noted that some patient groups have been receiving services that they do not need, which can result in either negative health impacts or neutral health impacts with unnecessary cost. The consumer representative relied on the clinicians’ advice about whether access would be positively or negatively impacted.
  • ΔThere was significant discussion about giving patients access to a Heart Team prior to a recommendation for treatment for coronary artery disease. The issue here is the balance between restricting access to specific procedures by making Heart Team involvement compulsory, ensuring the rights of the patient to choose whether the Heart Team should be involved, the timing of informed consent, and determining whether these access limitations result in better health outcomes for the patient or unnecessary delay and cost to the system. There was consensus that referral to a Heart Team was likely to result in better choices for the patient and better informed consent, but that it should not be required for all populations. Data should be collected to ensure that the desired outcomes (e.g., better patient outcomes) are achieved once this recommendation is implemented.
  • ΔThe issue of follow-up care after surgery (also called aftercare) was discussed and only partially resolved. The current system bundles the payment for follow-up care into the surgical fee. This means that patients with complex comorbidities or complications may have less access to extended follow-up care. This rule applies to the whole MBS and is being reviewed by the Principles and Rules Committee, which is responsible for these issues. It was recommended that the complex outcomes from changes to these rules be considered carefully.
  • ΔQuestions were asked about limiting access to a nuclear test in favour of a stress echo, given that both tests provide equivalent diagnostic relevance (for most patient groups), and that the nuclear test may cost more and involves radiation. The Committee supports using the lowest cost test but felt that more research was needed. The Committee took into account that there is better access to the nuclear test in some regional areas, and that it is bulk billed more often (on 92 per cent of occasions for the nuclear test versus 68 per cent for stress echo), which means that it has lower out-of-pocket costs for most patients. The Committee ultimately recommended that where both tests are accessible (including out-of-pocket cost considerations) and clinical effectiveness is equal, stress echo should be preferred as it does not involve radiation. The Committee also recommended adding a note to the MBS to encourage General Practitioners (GPs) to consider the cost to the MBS and the levels of radiation exposure when deciding with the patient what the best test is for them.
  • ΔClinicians’ own experiences suggest that some geographic regions are being serviced using older equipment, and that this older equipment delivers poorer images and higher radiation levels. However, some tests with equivalent efficacy vary in terms of availability, both geographically and between states, which makes it difficult to balance access against radiation exposure.

Effectiveness

  • ΔEffectiveness was not negatively affected by any of the recommended changes. Issues relating to diagnostic tests were discussed, specifically whether people should have immediate access to the new emerging gold standard tests (e.g., CT coronary angiogram), or whether there should be limited access to these tests until costs decrease and the supporting evidence is stronger. At present, this test is only available to specialists, but the Committee recommended that the MSAC consider allowing GPs to order it for some patient groups.
  • ΔThe Committee also considered whether patients should have to meet specific thresholds in lower cost tests before the more expensive tests are offered. It should be noted that there are potentially negative health outcomes associated with using high-technology tests in the wrong patient groups, or if abnormalities are identified that would have otherwise had no clinical impact (as some members suggested had occurred with knee MRI). This represents a trade-off between limiting access and improving targeting, and data should be collected to ensure that any changes result in improved health outcomes and increased cost-effectiveness.

Cost-effectiveness

  • ΔCost-effectiveness was generally positively affected by clarifying which patient groups should have access to specific tests, treatments and intervention. However, data will need to be collected in order to monitor the impacts of changes, and to respond quickly if needed.

Accountability

  • ΔThere is an opportunity to require specific data collection and reporting on meaningful key performance indicators to ensure that MBS item numbers are being used appropriately. Many of the changes included wording specifically intended to facilitate future auditing for quality purposes.

Data collection

  • ΔData collection for research, monitoring and auditing presents a huge opportunity for a revised MBS, and the conditions attached to the revised items should generally improve opportunities to use this data for targeted research in the future.
  • ΔDuring discussions, the Committee highlighted some research questions that are particularly relevant to consumers, including the following:
    1. What effect does introducing the Heart Team in the Australian setting have on health outcomes and informed consent?
    2. Does requiring certain tests before patients are eligible for more expensive tests result in better targeting of patient groups, improved individual health outcomes and lower overall costs? (For example, stress echo is a good test for showing functional effect such as ischaemia, but not anatomical CAD. CT shows anatomical CAD but not ischaemia and is more expensive. Stress ECG is the cheapest test, but if it is positive or uncertain, the patient may need another test. Which test should be used as gatekeeper?)
    3. What is the availability of high-quality tests in rural and remote regions and what can be done to improve this? Is it better for patients or the health system if they are sent to major centres for testing?
    4. Several of the recommended changes rely on clinicians using tools properly (e.g., the Australian Absolute Cardiovascular Risk Tool and the Duke Treadmill Score). Will all clinicians use these tools effectively, and how do we monitor and facilitate this?
    5. A substantial amount of the discussion among the Committee and Working Groups involved in this report focused on the appropriateness of various tests and interventions. Research into the health service and health policy drivers of more appropriate care is likely to lead to substantial benefits in terms of improved health outcomes and reduced health costs.
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