4. Cardiac imaging recommendations

4.1 Cardiac Imaging Working Group membership

The Committee formed a Working Group to consider cardiac imaging services, including echocardiogram (echo), stress echocardiogram (stress echo), exercise stress testing (EST) and myocardial perfusion scans (MPS). The Cardiac Imaging Working Group included the following members:

  • ΔProfessor Aidan Foy (Chair) – General Physician and Gastroenterologist; Clinical Dean Maitland Clinical School University of Newcastle and University of New England Joint Medical Program.
  • ΔDr Ruth Arnold – Cardiologist, Orange Health Service; Chair, Rural Working Party, Cardiology, Agency for Clinical Innovation (ACI), New South Wales.
  • ΔAssociate Professor John Atherton – Director of Cardiology, Royal Brisbane and Women’s Hospital; Associate Professor, Department of Medicine, University of Queensland.
  • ΔAssociate Professor Barry Elison – Director of Nuclear Medicine, Illawarra Shoalhaven Local Health District.
  • ΔDr Geoff Evans – Cardiologist, Charles Clinic Heart Care, Launceston, Tasmania and Rural Outreach Service.
  • ΔDr Walid Jammal – General Practitioner, Member, Evaluation Sub-Committee of the Medical Services Advisory Committee; Clinical Lecturer, University of Sydney Faculty of Medicine; Conjoint Senior Lecturer, Western Sydney University.
  • ΔProfessor Tom Marwick – Director, Baker IDI Heart & Diabetes Institute.
  • ΔMs Anne McKenzie – Independent consumer.
  • ΔDr 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
  • ΔAssociate Professor David Prior – Deputy Director of Cardiology, St Vincent’s Hospital, Melbourne; Associate Professor, University of Melbourne.
  • ΔDr Dave Richmond – Rural GP, Cowra NSW. Secretary and ex-president, Rural doctors Association of NSW.
  • ΔProfessor Richard Harper – Emeritus Director of Cardiology, Monash Medical Centre; Adjunct Professor of Medicine, Monash University (Ex-Officio).

The following recommendations were developed by the Cardiac Imaging Working Group and accepted unanimously, with the exception of the gatekeeper recommendation. (Dissenting views are noted in the relevant section.)

The Committee endorsed the recommendations unanimously.

4.2 Echocardiography

Current item descriptors and MBS data from FY 2014/15
Item 55113 – Schedule fee: $230.65 Services: 697,638      Total Benefits: $142,206,653      Average annual growth: 8.7% M-mode and two-dimensional real time echocardiographic examination of the heart from at least 2 acoustic windows for the investigation of symptoms or signs of cardiac failure, or suspected or known ventricular hypertrophy or dysfunction, or chest pain: (a) with: (i) measurement of blood flow velocities across the cardiac valves using pulsed wave and continuous wave doppler techniques; and (ii) real time colour flow mapping from at least 2 acoustic windows; and (iii) recordings on video tape or digital media; and (b) not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R)
Item 55114 – Schedule fee: $230.65 Services: 146,935      Total Benefits: $29,508,939      Average annual growth: 3% M-mode and two-dimensional real time echocardiographic examination of the heart from at least 2 acoustic windows for the investigation of suspected or known acquired valvular, aortic, pericardial, thrombotic or embolic disease or heart tumour: (a) with: (i) measurement of blood flow velocities across the cardiac valves using pulsed wave and continuous wave doppler techniques; and (ii) real time colour flow mapping from at least 2 acoustic windows; and (iii) recordings on video tape or digital media; and (b) not being a service associated with a service to which an item in subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R)
Item 55115 – Schedule fee: $230.65 Services: 56,377      Total Benefits: $10,829,483      Average annual growth: 4.5% M-mode and two-dimensional real time echocardiographic examination of the heart from at least 2 acoustic windows for the investigation of symptoms or signs of congenital heart disease: (a) with: (i) measurement of blood flow velocities across the cardiac valves using pulsed wave and continuous wave doppler techniques; and (ii) real time colour flow mapping from at least 2 acoustic windows; and (iii) recordings on video tape or digital media; and (b) not being a service associated with a service to which an item in subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (r)

Public data from 2014-15 (Department of Human Services)

Recommendation 1.1
  • ΔAdd all cardiac imaging items to the DHS MBS items online checker tool.
Recommendation 1.2
  • ΔRestructure the existing transthoracic echocardiography items into six new items:
    • Item 5511A: Initial complete echo.
    • Item 5511B: Serial echo for valvular dysfunction.
    • Item 5511C: Serial echo for heart failure or structural heart disease.
    • Item 5511D: Serial echo for complex or rapidly evolving congenital heart disease.
    • Item 5511E: Frequent repetition serial echo for specified indications, with a lower schedule fee to reflect the focused nature of these services.
    • Item 5511F: Repeat echo not covered by items A–E for exceptional circumstances. This should represent a very low proportion of a referrer’s services and should be closely monitored by compliance.

The descriptors and explanatory notes for these items are presented on the following pages.

Item 5511A

Initial real time echocardiographic examination of the heart with real time colour flow mapping from at least 3 acoustic windows for the investigation of:

  • ΔSymptoms or signs of cardiac failure; or
  • ΔSuspected or known ventricular hypertrophy or dysfunction; or
  • ΔPulmonary hypertension; or
  • ΔValvular, aortic, pericardial, thrombotic or embolic disease; or
  • ΔHeart tumour; or
  • ΔSymptoms or signs of congenital heart disease; or
  • ΔOther rare indications, in line with accepted clinical guidelines.
  • (a)Examination including the following:
    • i.Left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function should also be assessed; and
    • ii.Right ventricular structure and function with quantitative assessment where appropriate; and
    • iii.Left and right atrial structure including quantification of atrial sizes; and
    • iv.Vascular connections of the heart including the great vessels and venous structures; and
    • v.Pericardium and quantitation of any haemodynamic consequences of pericardial abnormalities; and
    • vi.Assessment of all 4 valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave Doppler techniques with quantitation of stenosis or regurgitation if present; and
    • vii.Assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and
    • viii.Recordings on digital media; and
    • ix.Detailed formal report, including relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.
  • (b)If the minimum requirements for views or recordings in criteria (a) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study.
  • (c)Not to be used as a screening test, in asymptomatic patients, or for routine surveillance in the absence of clinical changes, except in line with accepted clinical guidelines.
  • (d)Not claimable within 2 years of any complete echo (5511A-D, 5511F, 55116C or 55117C).
  • (e)Not being a service performed within 4 weeks of a stress echo (55116A-C, 55117A-C, 55116X, or 55116Y).
  • (f)Not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory note: Examples of other rare but acceptable indications include (but are not limited to): sudden death of an immediate relative, prior to the commencement of specific drugs which require cardiac monitoring, and for patients scheduled for cardiac surgery who have not previously had an echocardiogram.

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Item 5511B

Serial real time echocardiographic examination of the heart from at least 3 acoustic windows for the investigation of known valvular dysfunction.

  • (a)Performed at intervals in line with appropriate clinical guidelines or the intervals recommended in the explanatory notes.
  • (b)Examination including the following:
    • i.Left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function should also be assessed; and
    • ii.Right ventricular structure and function with quantitative assessment where appropriate; and
    • iii.Left and right atrial structure including quantification of atrial sizes; and
    • iv.Vascular connections of the heart including the great vessels and venous structures; and
    • v.Pericardium and quantitation of any haemodynamic consequences of pericardial abnormalities; and
    • vi.Assessment of all 4 valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave Doppler techniques with quantitation of stenosis or regurgitation if present; and
    • vii.Assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and
    • viii.Recordings on digital media; and
    • ix.Detailed formal report, including comparisons to previous imaging, relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.
  • (c)If the minimum requirements for views or recordings in criteria (b) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study.
  • (d)Not being a service performed within 4 weeks of a stress echo (55116A-C, 55117A-C, 55116X, or 55116Y).
  • (e)Not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory note: Recommended intervals adapted from the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease.

  • (a)Mild to moderate disease
    • i.Aortic stenosis should have a repeat every 3–5 years for mild disease and 1–2 years for moderate disease.
    • ii.Other valvular disease should NOT have repeat imaging more frequently than every 3 years for mild disease and every 1–2 years for moderate disease.
    • iii.Mild–moderate mitral stenosis does not require any repeat imaging unless clinical signs or symptoms change.
  • (b)Severe disease should be monitored in line with guidelines.

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Item 5511C

Serial real time echocardiographic examination of the heart from at least 3 acoustic windows for the investigation of patients with known heart failure or structural heart disease, excluding valvular dysfunction, and where:

  • (a)Changes in symptoms or cardiac examination have occurred since the last echo; or
  • (b)The patient is in a defined population as specified in the explanatory notes; and
  • (c)Examination including the following:
    • i.Left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function should also be assessed; and
    • ii.Right ventricular structure and function with quantitative assessment where appropriate; and
    • iii.Left and right atrial structure including quantification of atrial sizes; and
    • iv.Vascular connections of the heart including the great vessels and venous structures; and
    • v.Pericardium and quantitation of any haemodynamic consequences of pericardial abnormalities; and
    • vi.Assessment of all 4 valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave Doppler techniques with quantitation of stenosis or regurgitation if present; and
    • vii.Assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and
    • viii.Recordings on digital media; and
    • ix.Detailed formal report, including comparisons to previous imaging, relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.
  • (d)If the minimum requirements for views or recordings in criteria (C) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study.
  • (e)Claimable once in any 12 month period.
  • (f)Not being a service performed within 4 weeks of a stress echo (55116A-C, 55117A-C, 55116X, or 55116Y).
  • (g)Not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory note: [Standard text around co-claiming with a consultation.]

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Item 5511D

Serial real time echocardiographic examination of the heart from at least 4 acoustic windows for the investigation of complex or rapidly evolving congenital heart disease before or after cardiac surgery where:

  • (a)Transitional circulation, substantive age related changes, or rapid lesion evolution warrant review; or
  • (b)Cardiac surgery has required multilevel cardiac reconstruction; or
  • (c)Multilevel or bilateral congenital heart disease where an echocardiogram is clinically indicated but not covered by items 5511A–C, or 5511E.
  • (d)Examination including the following as minimum requirements:
    • i.Consistent with published paediatric and congenital heart disease echo protocols; and
    • ii.Ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function should also be assessed unless not clinically relevant due to underlying physiology or anatomy; and
    • iii.Atrial structure including quantification of atrial sizes unless not clinically relevant due to underlying physiology or anatomy; and
    • iv.Vascular connections of the heart including the great vessels and venous structures; and
    • v.Pericardium and quantitation of any haemodynamic consequences of pericardial abnormalities; and
    • vi.Assessment of all valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave Doppler techniques with quantitation of stenosis or regurgitation if present; and
    • vii.Assessment from the subxiphoid views recommended for congenital heart lesions; and
    • viii.Assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and
    • ix.Recordings on digital media; and
    • x.Detailed formal report, including comparisons to previous imaging, relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.
  • (e)If the minimum requirements for views or recordings in criteria (d) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study.
  • (f)Not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: It is expected that on average, fewer than 5% of a provider’s services would be claimed under this item, other than in a predominantly congenital heart disease practice or congenital heart programme where high frequency would be expected & permitted. However it is acknowledged that some providers in specific areas of clinical practice may have higher rates that are clinically appropriate and substantiation of this appropriateness may be requested by MBS compliance and will be considered during any clinical audit activities

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Item 5511E:

Frequent repetition serial real time echocardiographic examination of the heart from at least 3 acoustic windows for the investigation of patients:

  • ΔWith pericardial effusion or pericarditis; or
  • ΔOn chemotherapy which requires cardiac surveillance; or
  • ΔOn Clozapine; or
  • ΔCommenced on a medication which requires echocardiograms to comply with the requirements of the PBS; or
  • ΔWithin 3 months after cardiac surgery or catheter based structural intervention; or
  • ΔWith acute rapidly evolving cardiomyopathy; or
  • ΔWith pulmonary arterial hypertension.
  • (a)Performed at intervals in line with appropriate clinical guidelines.
  • (b)Focused examination including the following where appropriate:
    • i.Left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function should also be assessed; and
    • ii.Right ventricular structure and function with quantitative assessment where appropriate; and
    • iii.Left and right atrial structure including quantification of atrial sizes; and
    • iv.Vascular connections of the heart including the great vessels and venous structures; and
    • v.Pericardium and quantitation of any haemodynamic consequences of pericardial abnormalities; and
    • vi.Assessment of all 4 valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave Doppler techniques with quantitation of stenosis or regurgitation if present; and
    • vii.Assessment of additional haemodynamic parameters including the assessment of pulmonary pressures.
  • (c)If the minimum requirements for views or recordings in criteria (b) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study.
  • (d)Recordings on digital media; and
  • (e)Detailed formal report, including comparisons to previous imaging, relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.
  • (f)Not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: [Standard text around co-claiming with a consultation.]

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Item 5511F

Repeat real time echocardiographic examination of the heart from at least 3 acoustic windows for the investigation of patients where an echocardiogram is clinically indicated, the service does not meet the requirements of items 5511A–E, and the indication or rationale for the service is documented in the patient’s notes.

This item is intended to cover rare occurrences where a repeat echo is clinically indicated beyond the situations described in the primary echo items. The indication or rationale is documented.

Note: High usage of this item may trigger a compliance alert.

  • (a)Examination including the following:
    • i.Left ventricular structure and function including quantification of systolic function using M-mode, 2-dimensional or 3-dimensional imaging and diastolic function should also be assessed; and
    • ii.Right ventricular structure and function with quantitative assessment where appropriate; and
    • iii.Left and right atrial structure including quantification of atrial sizes; and
    • iv.Vascular connections of the heart including the great vessels and venous structures; and
    • v.Pericardium and quantitation of any haemodynamic consequences of pericardial abnormalities; and
    • vi.Assessment of all 4 valves including structural assessment and measurement of blood flow velocities across the valves using pulsed wave and continuous wave Doppler techniques with quantitation of stenosis or regurgitation if present; and
    • vii.Assessment of additional haemodynamic parameters including the assessment of pulmonary pressures; and
    • viii.Recordings on digital media; and
    • ix.Detailed formal report, including comparisons to previous imaging, relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.
  • (b)If the minimum requirements for views or recordings in criteria (a) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study.
  • (c)When performed within 4 weeks of a stress echo (55116A-C, 55117A-C, 55116X, or 55116Y) the report must specifically document the clinical change(s) in the patient’s condition since the stress echo to warrant a separate study.
  • (d)Not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: It is expected that on average, fewer than 5% of a provider’s services would be claimed under this item. However it is acknowledged that some providers in specific areas of clinical practice may have higher rates that are clinically appropriate, and substantiation of this appropriateness (such as compliance with guidelines or best practice) may be requested by MBS compliance and will be considered during any clinical audit activities.

Examples of potential indications for which this item would be appropriate include a repeat study performed every 1–2 years WITHOUT change of symptoms or changes on cardiac examination for:

  • (1)A patient eligible for transplant; or
  • (2)The surveillance of patients with hypertrophic obstructive cardiomyopathy (HOCM); or
  • (3)A patient who has a history of known familial syndromes.

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Rationale

These recommendations focus on modernising the MBS and supporting best practice care and are based on the following observations.

Overview

  • ΔThe Committee noted that echos (excluding stress echos) account for over 900,000 services and over $180 million in annual benefits, with average growth in service volume of 7 per cent per year over the last five years. As one of the single largest imaging services on the MBS, it warrants careful consideration.
  • ΔThe Committee noted that twice the numbers of services per population were performed in the eastern states (Figure 3), and that there was some variation by rurality. It felt that the high annual growth and geographic variability represent significant practice variation, including over- and under-servicing. This view is supported by the published literature (1).
    Figure 3: Geographical variation of echo usage (items 55113, 55114, 55115, 55119, 55120, and 55121)
    Figure 3 is a bar graph that shows geographical variation of echo usage. There are two bar graphs, one that depicts state-based variation and another for rurality based variation. State-based variations shows that NSW, followed closely by SA, QLD and VIC have upto twice as many services per capita as other states. NSW is the highest at 4,538 services per 100,000 population, followed by QLD at 4,017 and SA at 4,019. VIC, WA, TAS, NT and ACT are all under 4,000. Rurality-based variations outlines that Inner regional is the highest at 4,218, followed by major city at 3,796 and outer regional at 3,694. Remote and very remote are under 3,000.

    Unpublished data, based on date of service for Medicare claims processed between July 1 2014 and April 30 2016 extracted on 20 June 2016 (Department of Health). Remoteness Area classes are based on the Accessibility and Remoteness index of Australia (ARIA). Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file.

  • ΔMBS data showed that 11 per cent of services are same-year repeats, and that 40 per cent of services are repeat studies conducted during a five-year window. The Committee agreed that it is likely that a significant number of initial and repeat services are for inappropriate indications, which represents low-value care. Reducing this low-value use is difficult, however, given the broad indications for which echos are clinically useful and valuable studies.
  • ΔThe Committee agreed that the indications for repeat studies are more specific than for an initial echo, and it recommended a revised item structure to reflect this. A structure consisting of four items was proposed: initial echo, serial echo for valve pathology, serial echo for heart failure or structural pathology, and frequent repetition serial echo for specific indications. The Committee agreed that these changes align with good clinical practice and would not result in any significant negative impact on patient access or outcomes. It noted that it is not possible to completely define appropriate use, and that the intent of these changes is to prevent low-value, high-frequency studies.
  • ΔThe Committee also agreed that high-quality, conscientious providers often treat patients who need an echo but do not fit within the guidelines, or who may have had a recent study that the provider is unable to obtain. Such cases are rare, but the Committee felt that it was important for a rebate to remain payable in these instances. It agreed that item 5511F should be created for exceptional cases, accounting for less than 5 per cent of a provider’s volume. It also recommended that the MBS audit and compliance team monitor usage of this item closely. Should overall service volume for this item account for more than 5 per cent of echo services in the 6–12 months following implementation, a detailed review is recommended.
  • ΔThe Committee agreed that a previous low-quality or inadequate study is a common indication for a repeat echo. The descriptors have therefore been revised in line with the Cardiac Society of Australia and New Zealand’s (CSANZ) position statement on training and performance in adult echos (11).

Initial studies

  • ΔThe Committee agreed strongly that echos should not be performed as a screening test, in asymptomatic patients, or for routine surveillance in the absence of clinical changes, except in line with accepted clinical guidelines. It agreed that the current indications should be retained, with the addition of “other indications in line with accepted clinical guidelines” to provide future-proofing and cover for rare indications such as specific familial syndromes. The Committee agreed that this addition is unlikely to result in a significant increase in volume as the current item descriptors already provide a very broad scope.
  • ΔThe Committee agreed that it was appropriate to restrict the item for initial complete study (item 5511A) to not more than once every two years, with additional repeat items created to allow more frequent services for specific indications, with appropriate intervals. Although it may be clinically appropriate to have a longer interval, this could create practical issues in the absence of a personal health record or global database system. Patients often cannot tell a doctor what investigation they have had, let alone where and when. Tracking down studies (reports and/or pictures) from other providers would create considerable work for practitioners, at the cost of staff time. Such an expectation would be unrealistic and could disadvantage patients, who may receive non-rebatable services. As a result, restrictions to these items require the addition of all cardiac imaging items to the Health Professionals Online Services (HPOS) MBS item online eligibility checker to allow providers to confirm patient eligibility prior to providing the service. This will prevent patients from being left out of pocket having received non-rebatable services. The Committee also recommended that efforts should continue to support the creation of a centralised system for the storage of imaging reports and images.
  • ΔThe Committee recommended creating three items for repeats due to the variable intervals and criteria appropriate to each collection of indications.

Valvular dysfunction

  • ΔThe Committee recommended creating an item (5511B) for repeat studies related to known valvular dysfunction. This item would require examination of the whole heart, including cardiac valves and ventricular function.
  • ΔClinical guidelines for the investigation and management of valvular dysfunction are complex, as they account for valve, pathology and severity. It is therefore not practical to create unique items for all valve and severity combinations. For this reason, the Committee recommended aligning the interval for repeat studies with the relevant international guidelines, such as those published by the American Heart Association (AHA). Guidance has been provided in the explanatory notes for this item, which outline the intervals for mild to moderate disease (which accounts for the majority of patients and low-value repeats). This guidance has been adapted from the 2014 AHA/American College of Cardiology (ACC) guidelines and simplified in order to be more suitable for the explanatory notes.

Heart failure and structural pathologies

  • ΔThe Committee recommended creating an item (5511C) for repeat studies related to known heart failure or structural heart disease, excluding valvular dysfunction, where one of the following are true: (i) changes in symptoms or cardiac examination have occurred since the last echo; (ii) the patient is eligible for transplant; (iii) the study is for the surveillance of a patient with hypertrophic obstructive cardiomyopathy (HOCM); or (iv) the patient has a history of known familial syndromes. The Committee considered whether this item could be a focused study, but it ultimately agreed that a complete study is good clinical practice.
  • ΔThe Committee agreed that restricting repeats to once every 12 months was reasonable; noting that such repeats will generally require symptom evolution to be claimable. It acknowledged that symptom evolution is subjective, and that a provider could easily say that symptoms have worsened slightly. However, it felt that this restriction would nonetheless encourage judicious providers to order studies more appropriately.

Complex congenital heart disease

  • ΔThe Committee recommended creating a specific item for complex multilevel or bilateral congenital heart disease, noting that frequent imaging may be required, particularly in the perioperative period. This is not suitable as an indication for item 5511E, as the studies are complete (not focused) and time-consuming to perform, due to complex anatomy and patient age. The lower rebate for item 5511E would therefore be inappropriate for this service.
  • ΔThe Committee considered a blanket exception for paediatric patients to allow unrestricted access to imaging. However, with the exception of complex congenital heart disease, it felt that the descriptors for adult populations would also be suitable for paediatric patients. Providers using item 5511F (for indications not covered by items A-E) should be providing services consistent with Australian best-practice guidelines for paediatric echocardiography or the relevant adult guidelines as appropriate (12-14).

Conditions requiring high-frequency serial echo

  • ΔThe Committee noted that there is a specific group of indications for which there is evidence supporting frequent echo surveillance. For this reason, it recommended an item to specifically account for these indications (item 5511E), which are listed in the draft descriptor. It agreed that these studies could be more targeted, focusing on comparison of specific views with previous studies. The Committee therefore recommended that this service should receive a lower MBS rebate.
  • ΔDue to the variable nature of these indications, the Committee recommended that intervals should align with the appropriate clinical guidelines.

Other considerations for repeat services

  • ΔConsideration was given to restricting repeats for same providers only. However, this has been identified as an ineffective approach, as large urban centres frequently have multiple providers, while rural areas may only have a single provider. As a result, the restriction would apply for all patients in rural areas, but could be easily circumvented in urban settings. The Committee felt that this was an inequitable solution.

Schedule fee for repeat studies

  • ΔThe Committee agreed that all patients should initially receive a complete study to ensure important diagnoses are not missed. In serial studies, some patients may be suitable for a more focused study (i.e., of ventricular function only). However, good clinical practice would involve a complete repeat echo. The Committee acknowledged that some repeat studies may be more targeted and faster to perform, and in such instances it would be reasonable to consider a lower schedule fee. However, the Committee also noted that many repeat studies are equally time-consuming when performed well, with all views repeated. When comparison with previous images is provided, potential time-savings are further diminished. Although comparison with previous images is valuable, previous images are not always accessible in the absence of a centralised image storage system. For this reason, the items for repeats should not require comparisons in all studies.
  • ΔAs noted above, the Committee felt that high-frequency serial echos were sufficiently different from standard echos and appropriate for a clinically focused repeat with a lower MBS fee.

Co-claiming with stress echo

  • ΔThe items for echos and stress echos have a restriction on them to prevent same-day co-claiming. As a result of this, patients are required by some providers to attend for an echo and then return on a subsequent day for a stress echo. The Committee noted that the current wording of the stress echo item—which requires a baseline but specifies matched pre/post-stress views—is unclear on if it is intended to include a complete baseline echo, as not all baseline views have a post-stress component. As a result, some providers perform services a split over multiple days to enable both the standard echo and stress echo services to be claimed. The Committee noted that this outcome is not beneficial for patients and represents low-value use of health resources. It therefore recommended changes to the stress echo items to provide clarity of required baselines and to allow patients who clinically require both studies to receive them. These changes are outlined in the stress echo section of the Report. Corresponding changes to the co-claiming restrictions on the echo items have been recommended here, such as extending the co-claiming restriction with stress echo services to 4 weeks, with the exception of item 5511F which is retained for urgent and exceptional circumstances where a patient requires a structural echo in the days immediately after a stress echo has been performed.

Complete medical service

  • ΔThe Committee noted that 20–30 per cent of echo services were co-claimed with a consultation, and that 15 per cent were co-claimed with an ECG (Figure 4). It agreed that there are some instances where co-claiming a consultation is appropriate—for example, where a rural or remote patient has a post-consult echo squeezed in on the same day, or has a pre-consult echo booked on the same day (in advance), based on the patient’s clinical history but without knowing his or her current clinical status. It was noted that local patients often receive pre-consult studies too, although this usually occurs in the days prior to the consultation. This is believed to reduce the likelihood of a patient requiring a consult to determine the need for a repeat echo, followed by a second consult to interpret the echo and make management decisions.
  • ΔThe Committee recommended referencing or including MBS co-claiming restrictions—as agreed by the Principles and Rules Committee—in the descriptor, to ensure that providers are aware of these requirements. However, a hard block should not be placed on this practice.
  • ΔThe majority of co-claiming with ECGs occurs with a consultation and may be appropriate. Co-claiming with an echo when not requested by the referring provider is inappropriate and should not be performed. A hard rule is not proposed, but the MBS audit and compliance team may wish to monitor this issue over time to identify outlier providers who may be co-claiming more frequently.
Figure 4: Top services co-claimed with echocardiograms
Figure 4 is a table showing the top services co-claimed with echocardiograms. There are 3 main columns - the first column lists the commonly co-claimed items, second and third columns has 2 sub columns each which shows the number and percentage of episodes that have been co-claimed with echo item numbers 55113 and 55114. Specialist consults are the highly co-claimed for both item numbers at 22% and 28% respectively. Second highest co-claimed is 12-Lead ECG at 16% and 15% respectively.

1 Specialist consult includes items 104, 110, 116, 119, 132 or 133. 12-lead ECG item 11700. Holter items 11709. Stress ECG items 11712. TOE items 55118. Chest X-ray 58503.

Unpublished data, extract based on date of service in financial year 2014-15. The reference period for trigger items, was July-Dec 2014 which includes episodes plus/minus six weeks of trigger item, which includes services from mid Nov 2013 to mid Feb 2015. (Department of Health).

Self-referral

  • ΔThe Committee considered whether removing the ability of providers (predominantly cardiologists) to self-refer for echo services would improve the value of the services provided. It was acknowledged that self-referred services may be more likely to be performed at a lower threshold and may therefore be of lower value. However, the Committee felt that a restriction on self-referral would be evaded by providers in larger practices (who could refer to each other), but could not be evaded by rural providers, who may practise independently. Although there is already a restriction on same-practice cross-referral for Diagnostic Imaging Services Table (DIST) items, the Committee felt that a more appropriate solution would be to improve the descriptors for the items. Further consideration of this issue could be undertaken if the proposed changes do not sufficiently reduce low-value services.
  • ΔThe Committee agreed that educating providers to ensure that they understand that they (not the referrer) are accountable for compliance with the descriptors may have some effect, although services are often performed by a sonographer before a clinician is involved. Random audit and other compliance activity would be appropriate to ensure providers with significantly higher rates of echo per consultation are complying with descriptors.

Formal reports

  • ΔThe Committee noted that when a patient is referred to a cardiologist and receives an echo, the referring provider may receive a letter from the cardiologist but not a formal report on the echo. It felt that a letter from a cardiologist does not meet the definition of a formal report, which should include all relevant measurements and findings. As an imaging service on the DIST, the provision of a report is expected, and both the images and reports are expected to be stored in compliance with DIST requirements. Providers who do not currently provide a report may be in breach of MBS requirements. Given that echo studies are performed by a broader provider base than many other studies, the Committee recommended including the requirements for formal reports in the descriptors for these items.

4.3 Exercise stress testing

Current item descriptors and MBS data from FY 2014/15
Item 11712 – Schedule fee: $152.15 Services: 464,040     Total Benefits: $60,685,140     Average annual growth: 3.5% Multi channel ECG monitoring and recording during exercise (motorised treadmill or cycle ergometer capable of quantifying external workload in watts) or pharmacological stress, involving the continuous attendance of a medical practitioner for not less than 20 minutes, with resting ECG, and with or without continuous blood pressure monitoring and the recording of other parameters, on premises equipped with mechanical respirator and defibrillator

Public data from 2014-15 (Department of Human Services)

Recommendation 2
  • ΔChange the descriptor for item 11712, using the proposed wording below.

Item 11712

Multi-channel ECG monitoring and recording during exercise (motorised treadmill or cycle ergometer capable of quantifying external workload in watts) for the investigation of symptoms consistent with cardiac ischaemia or other cardiac disease, which are exacerbated with exercise.

Performed with:

  • (a)The continuous attendance of a medical practitioner capable of recognising symptoms and signs of cardiac disease, who has training in exercise testing and is capable of interpreting the exercise test findings, for the duration of the procedure; and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. On premises equipped with standard resuscitation equipment and defibrillator; and
  • (b)Resting ECG with or without continuous blood pressure monitoring and the recording of other parameters; and
  • (c)With documentation in the report of the calculated Duke Treadmill Score and how the indication requirements of the descriptor were met.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) within 5 years of a high quality CTCA with a normal calcium score and no plaques; or (v) where the patient has an abnormal resting ECG which would prevent the interpretation of results.

Claimable once in any 24 month period.

Explanatory notes: A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

Rationale

This recommendation focuses on modernising the MBS and is based on the following observations.

  • ΔThe Committee noted that although the total number of services for EST has increased over the last five years, this increase is driven heavily by co-claiming with stress echo and MPS services. The number of stand-alone EST services has declined by an average of 5 per cent per year over the last five years, driven primarily by the increased use of stress echo.
  • ΔAlthough the volume of EST has been decreasing, it was agreed that low-value studies are still being performed, such as functional studies of any kind in asymptomatic patients for family history of ischaemic heart disease (IHD) alone—an indication that the Committee unanimously considered inappropriate. For this reason, the Committee recommended restricting the service to the investigation of symptoms consistent with cardiac ischaemia, which are exacerbated by exercise (including walking or using the stairs). It was noted that there may be a very small number of patients who have cardiac disease that is not exacerbated by exercise, but the Committee agreed that truly ‘silent’ disease is exceedingly rare, most patients have symptoms of some description, and that an EST would be of low yield and value in such cases. Further specific exclusions are recommended for asymptomatic patients, population screening, and patients with abnormal resting ECGs, which would impede a provider’s ability to interpret results. In these populations, the Committee felt that EST was clearly unacceptable as these are low-value indications.
  • ΔThe Committee discussed the addition of an indication for screening asymptomatic diabetic patients who have silent ischaemia or small vessel disease. Although diabetic patients may have painless disease, it was not agreed that these patients have truly ‘silent’ disease without any symptoms, such as poor exercise tolerance and shortness of breath. The Committee agreed that, at present, there is insufficient evidence to justify the screening of diabetic patients with EST(15,16).
  • ΔRepeat studies within 24 months were agreed to be of low clinical value, except for patients who undergo revascularisation followed by required testing to assess other moderate/non-stented disease, or to investigate new symptoms. However, for these patients, a stress echo or MPS would be a more detailed and appropriate investigation. The Committee therefore recommended a restriction of no repeat studies within 24 months, as well as exclusion of use for surveillance of known cardiac disease in the absence of symptom evolution since the last study. The Committee agreed that this would not have a negative impact on patient outcomes. It was noted that for some patients, a submaximal study may be conducted to determine an appropriate exercise program (i.e., four to six weeks post-revascularisation), but this is generally a very short study and would be appropriate to perform as part of a routine follow-up consultation.
  • ΔIt was noted that work-related or personally desired stress tests that do not comply with the descriptor (i.e., required annually) are of low clinical value and should not be funded by the MBS. However, such services should continue to be available where privately funded.
  • ΔThe Committee noted that 49 per cent of ESTs are co-claimed with a consultation. It agreed that this was higher than is acceptable. In line with the emerging recommendations of the Principles and Rules Committee, it agreed that it is inappropriate to co-claim a consultation if a patient is specifically referred for an investigation by another provider. Co-claiming is appropriate in instances where a referral is for a consultation, and the specialist decides during the consult to perform a same-day EST. The Committee recommended that the MBS audit and compliance team routinely audit providers who co-claim EST at a higher rate than their peers.
  • ΔThe reference to pharmacological stress was removed because pharmacological stress ECGs are no longer performed as stand-alone services, and because item 11712 will no longer be co-claimable with stress echo/MPS items, which are being revised to include the exercise component as part of their complete services.
  • ΔThe Committee agreed that a Duke Treadmill Score (DTS) should be calculated for all studies and included in the report. This is best practice and is already current practice for the majority of providers. The requirement here will improve practice and support later recommendations for which DTS can be an indication for subsequent services.
  • ΔThe Committee agreed that the term ‘mechanical respirator’ was outdated and recommended using the more modern term ‘standard resuscitation equipment’ instead. This is generally a ‘resus trolley,’ which includes a bag valve mask and defibrillator at a minimum.

4.4 Gatekeeper for cardiac imaging

Recommendation 3
  • ΔFor GPs, Consultant Physicians and Cardiologists, standard EST (rather than stress echo or MPS) should be the first-line investigation for symptomatic adult patients with suspected CAD and an Australian Absolute risk score for cardiovascular event of less than 10 per cent over 5 years, and who have an interpretable ECG and are able to exercise. This should be reflected in the revised MBS descriptors.

Rationale

This recommendation focuses on encouraging best practice and improving the value of care provided by the MBS. It is based on the following observations.

Overview

  • ΔThe Committee agreed on two core principles that are central to this recommendation. Firstly, coronary investigations are best considered from a prognosis-and-outcomes perspective, rather than a risk-of-anatomical-disease perspective. This reflects a paradigm shift in the literature, moving away from how CAD has previously been considered by many clinicians. Secondly, the population in question are patients with atypical/uncertain symptoms—as defined by the National Institute for Health and Care Excellence (NICE) guidelines (i.e., low or intermediate risk of obstructive CAD)—who are able to exercise and have an interpretable ECG, and who have an Australian Absolute risk score for cardiovascular event of less than 10 per cent over five years.
  • ΔThe other recommendations described in this report allow access to functional imaging or CTCA (including for GPs) for patients who do not fall into this low-risk category. Appendix B provides a visual representation of the gatekeeper to functional imaging recommendation.

Considerations

  • ΔStress echos are increasing at a rate of 12 per cent per year and now outnumber the less expensive standard EST by more than four to one, with 70 per cent of referrals for stress echos coming from GPs. Medicare statistics show that stress echos and MPS lead to a revascularisation procedure within 6 weeks in only 1–3 per cent of cases regardless of referring provider specialty (Table 2). A one month sample population (n=22,717) was followed for 18 months and the revascularisation rates remained 2-3% for both modalities (9). Furthermore, there is marked variation in the rate of functional imaging per 100,000 population between states. For example, New South Wales’ rate of stress echos is more than three times the rates of South Australia and Western Australia (Figure 5). This variation is even more marked between Medicare locals, some of which have rates of stress echo up to 10 times higher than others (1). There is no evidence that this variation influences patient outcomes, and although there is almost certainly under-servicing in some areas, there is undoubtedly over-servicing in other areas.
    Table 2: Revascularisation rate of cardiac investigations
    Requesting provider EST MPS SE
    Cardiologist 1.7% 2.2% 2.0%
    Other Specialist 1.2% 1.7% 1.8%
    GP 1.2% 1.3% 1.4%
    Radiologist 0.6% 2.7% 1.0%
    Surgeon 0.0% 0.8% 1.2%
    Total episodes investigated 69,386 39,660 123,424

    Cardiac investigations includes EST item 11712. MPS items 61302, 61306, 6151, 6152, 6153, 61303, 61307, 61654. SE items 55116, 55117, 55122, and 55123. Revascularisation included services for CABG (items 38497, 38498, 38500, 38501, 38503, 38504) or PCI (item 38306) within 6 weeks (prior and/or post) of the ‘trigger” cardiac investigation(s) items. The reference period for the trigger items is between July-Dec 2014 by date of service using date of processing data from April 2014 to June 2016. Department of Health.

  • ΔMore broadly, the ratio of cardiac investigations to revascularisation has been steadily increasing over the last 10 years. Growth in CAD diagnostics has averaged 6 per cent per year (Figure 6), while growth in revascularisation therapeutics has remained relatively flat, with PCI and angioplasty growing at 3 per cent per year and CABG static at almost zero growth over 10 years. As a result, the average number of diagnostics per therapeutic has increased from 22 in FY2005/06 to 30 in FY 2014/15 (Figure 7).
    Figure 5: Geographical variation in stress echo services (items 55116, 55117, 55122, and 55123)
    Figure 5 is a bar graph that shows geographical variation of stress echo services. There are two bar graphs, one that depicts state-based variation and another for rurality based variation. State-based variations shows a 4 fold variation withNSW the highest at 2,912 services per 100,000 population. All the other states are under 1,800, with ACT at 961 and NT at 778 as the lowest. Rurality-based variations outlines that major cities are the highest at 1,202, followed by inner regional at 883. Outer regional is 620, remote 344 and very remote at 208. This is an almost 6 fold variation.

    Unpublished data, extract based on date of service for Medicare claims processed between July 1 2014 and April 30 2016 (Department of Health). Remoteness Area classes are based on ARIA. Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file.

    Figure 6: Growth in CAD diagnostic services since FY2005/06
    Figure 6 is an area chart that shows the growth in CAD diagnostic services since 2005-06. Y-axis is the number of services and the x-axis years starting 2005/06 until 2014/05. Overall, CAD diagnostic services have increased from around 600,000 per year to 1 million per year, an average increase of 6% per year. This is broken down by investigation and shows that ICA, stress echo and exercise stress tests are the largest services by volume. The growth rates per year for each test are, CTCA 22%, ICA 2%, EST 4%, stress echo 14%, FFR 67% and MPS 1%. Note that FFR is not visible on the chart as the volume of services is too low. Footnotes show that growth is a 10 year average except for CTCA which is a 3 year average as only newly introduced.

    Unpublished data, extract based on date of service, financial years 2005-6 to 2014-15 (Department of Health). 1 Compound annual growth rate over 10 years. 2 CTCA compound annual growth rate is calculated over 3 years since introduction. Item 57360, 57361. 3 FFR: 3,692 services in financial year 2014-15 and not visible due to the figure scale, CAGR over 9 years since introduction. Item 38241. 4 Population growth and aging each account for 1 -2% growth. Angiography items 38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240, 38246, 59973, 59925, 59970, and 59971. Exercise stress 11712.MPS items 61303, 61307, 61654, 61302, 61306, 61651, 61652, and 61653.

    Figure 7: Average ratio of CAD diagnostic to therapeutic services
    Figure 7 is a bar graph that shows the average ratio of CAD diagnostic to therapeutic services. X-axis shows financial years commencing 2005/06 until 14/2015 and y-axis shows the number of services. The graph slopes strongly upwards over time. Overall, there has been an average increase of 4% annually. From 22 diagnostics in 2005-06 to 30 diagnostics per therapeutic by 2014-15.

    Diagnostic services include CTCA (items 57360, 57361), angiography (items 38215 - 38246, 59973, 59925, 59970, 59971), exercise stress (item 11712), stress echo (items 55116-55123), FFR (item 38421) and MPS (items 61303 – 61653). Therapeutic services include PCI (item 38306), angioplasty (items 38300, 38303) and CABG (items 38498, 38500, 38501, 38503, 38504). Unpublished data, extract based on date of service, compound annual growth rate over financial years 2005-6 to 2014-15 (Department of Health).

  • ΔAlthough the growth of MPS has remained low (less than 1 per cent per year over the last five years), it is clinically interchangeable with a stress echo for many patients. This clinical equivalence necessitates that changes to access for either study must be applied to the other to avoid significant unintended volume shifts. These studies are collectively referred to as functional (stress) imaging.
  • ΔThe Committee agreed that a large number of patients currently undergo stress imaging, despite having a very low probability of CAD and a very low risk of having a cardiovascular event (such as a heart attack). The reasons for this are complex and may include lack of education, demand from patients for tests, and a desire to use the ‘best’ test, which is often considered to be the one with the highest sensitivity and specificity for anatomical CAD. The Committee noted that patient demands may be a particularly significant factor, with patients wanting to know whether their symptoms are coming from their heart, rather than the risk of a heart attack over five years. The consumer representative noted that although patients often want definitive answers, these are rarely available. The Committee supported this view. It would be appropriate for a patient to receive an explanation from his/her doctor that an assessment of their symptoms and risk factors placed them at a very low risk of having an event within five years and the DTS further reinforced this, but that they should actively manage their risk factors to reduce the risk of problems in the future.
  • ΔThe Committee agreed that for a population with a very low probability of CAD, low event rates would be expected for any diagnostic test. It agreed that for patients with low probability, there is no difference in outcomes between EST and stress echo, and many of these patients may not need any investigation at all. The proposal is not a binary approach to stress testing; high probability patients are identified by typical angina, while low and intermediate probability patients, based on symptoms, undergo an Australian Absolute risk assessment. Those with an Australian Absolute risk of event less than 10 per cent over five years who need an investigation would receive an EST, which applies the DTS. Patients with a DTS between +4 and -10 have an indeterminate result and are eligible to receive follow-up functional imaging, if clinically appropriate. Those with a greater than 10 per cent Absolute risk have the option of either a CTCA to identify anatomical disease or functional stress imaging. Those in whom the CTCA shows obstructive CAD with lesion(s) greater than 50 per cent, or those with lesions of indeterminate severity, can then undergo stress imaging to determine if the lesions are functionally significant or not. Depending on their response to optimal medical therapy, patients with functionally significant lesions may be eligible for invasive coronary angiography with a view to revascularisation if appropriate anatomy was present.
  • ΔAlthough any level could be considered arbitrary, the expert consensus of the Committee was that a 10 per cent Australian Absolute risk of event over five years is an appropriate cut-off. This is already used as the threshold for starting to consider statin therapy, and it was agreed to be an acceptable way of determining when imaging would be indicated, thereby reducing low-value imaging in low-risk patients. The entire purpose of investigating patients with atypical/uncertain symptoms is to identify those with significant risk factors who may be missed by symptom definitions, and the purpose of the 10 per cent cut-off is to better target the use of CTCA in this way. As always, referral to a cardiologist or consultant physician is available to GPs for any patient they are concerned about.
  • ΔThe AHA guidelines list EST as a class 1A recommendation for patients with intermediate probability of CAD and an interpretable ECG (7). The European Society of Cardiology (ESC) guidelines list EST as class 1B (the same as stress echo and MPS), noting that EST is a completely non-invasive, broadly available and low-cost technique that performs well at intermediate pre-test probabilities between 15 per cent and 65 per cent in patients with a normal resting ECG (no ST–T abnormalities) (6). Although the NICE guidelines recommend against the use of EST as a test for the exclusion of CAD, it was noted that the evidence cited for this relates to anatomical disease (8). For the exclusion of anatomical disease, CTCA or ICA should be used, but the Committee agreed that EST with DTS was an appropriate gatekeeper to functional imaging, with the aim of reducing low-value imaging in patients with an Australian Absolute risk of less than 10 per cent over five years and a DTS greater than five.
  • ΔThe Committee agreed that although stress echos and MPS have superior sensitivity and specificity compared with EST for the anatomical diagnosis of CAD (as determined by ICA), outcomes and anatomical diagnosis are not the same thing. The addenda to the ESC guidelines state that there is no evidence that superior ‘diagnostic’ accuracy leads to improved patient outcomes (2).
  • ΔThe Committee noted that there is not a large amount of published literature comparing the outcomes of functional imaging with EST. Two published studies in the New England Journal of Medicine and the Journal of the American Board of Family Medicine demonstrated concordant results: for the typical patient seen in general practice with symptoms suggestive of a low to intermediate probability of obstructive CAD, a negative EST has a strong negative predictive value (in the order of 99 per cent over four years) for adverse cardiovascular outcomes such as heart attack or death (4,5). At the time of writing, there was no prospective randomised data demonstrating that the superior diagnostic performance of functional imaging translates into superior outcomes over EST. Indeed, the Committee noted that in the recent ESC guidelines, which include a comprehensive literature review, only one randomised study comparing functional testing (in this case, MPS) to EST showed equivalent outcomes (3). A 2008 article in the British Medical Journal showed that for patients with suspected angina presenting to hospital chest pain clinics, neither 12-lead ECG nor EST provided additional prognostic information over specialist clinical assessment(17). This article did not address the question of the incremental value of stress echo or MPS however other studies have similarly called into question the value of stress echo above clinical assessment(18,19). No studies show EST to be a poor predictor of outcomes in the specific low-risk population the gatekeeper would apply to.
  • ΔThere is conflicting evidence regarding the effectiveness of specialist history and examination compared with EST and stress echo in determining likely outcomes from CAD (4,17–19). The Committee agreed that accurate clinical assessment of anginal symptoms is the best predictor of obstructive CAD. However, patients often demand some form of investigation, and referral of the entire population of patients with symptoms possibly due to obstructive CAD seen by GPs would both overwhelm specialists and potentially not avoid the demand for testing, especially taking into account the reassurance that such testing provides. Of the available tests, EST has a considerably lower cost (MBS fee: $152.15) compared with stress echo (MBS fee including EST: $337.73) and MPS (MBS fee including EST: $785.78–910.98).
  • ΔThe consumer representative asked if this recommendation would result in ‘placebo’ tests being performed, which may falsely reassure consumers. The Committee noted that another recommendation requires the calculation of DTS for all EST services and agreed that DTS is a prognostically powerful tool that is far from a placebo test. Patients who exercise to a high level without ECG evidence of ischaemia have an excellent prognosis (4,20). Those who do not exercise adequately will have an intermediate score on that basis alone and will be eligible for functional imaging, which is allowed in these recommendations. It was noted that even in the United States, where imaging is heavily used, a stress echo is considered inappropriate as the first-line investigation in patients with a low pre-test probability of CAD who have an interpretable ECG and are able to exercise (21). It is also important to note that while a negative anatomical test (ICA or CTCA) can exclude disease, a negative functional test of any form (MPS, stress echo or EST) does not exclude anatomical disease and risk factor modification should still be considered.

Specific concerns

The Committee discussed a number of potential concerns when developing this recommendation.

  • ΔThe risk of false positive results in women.
    • A concern was discussed about the risk of false positive EST in women. The available evidence is linked to anatomical diagnosis and is thought to be related to the interpretation of ST changes without the additional consideration of duration of exercise. The NICE guidelines note that such challenges may have arisen due to thresholds for abnormal being defined almost exclusively in men (8).
    • The Committee agreed that the likelihood of false positive results in both men and women diminishes as DTS increases, and it noted that a positive result (DTS ≤ -11) typically leads to cardiologist referral, which would be appropriate. DTS takes into account the degree of ST change and time exercising. A DTS less than or equal to -11 leading to ICA and an indeterminate result (DTS between -11 and +5) leading to stress echo would be appropriate in most circumstances. The objective nature of the DTS will reduce the ‘fudging’ of results to allow access to inappropriate downstream investigations, although this cannot be entirely prevented. Compliance efforts could monitor the rate of downstream investigations for EST providers to identify outliers who, for example, may be under-reporting DTS in order to classify patients as equivocal. Changes to downstream investigations recommended in this report support attempts to reduce inappropriate investigation and revascularisation of patients.
  • ΔThe risk of false negative results.
    • The Committee agreed that a DTS greater than or equal to five in a patient with atypical symptoms and an Australian Absolute risk score of less than 10 per cent over five years is very unlikely to be a false negative. Such a patient is extremely unlikely to have significant obstructive CAD and is therefore at a low risk of an adverse cardiovascular event. A patient who does not exercise to a high level (for whatever reason) will have a lower DTS and may then progress to either referral to a cardiologist or functional imaging. Although no test is able to perfectly predict the future, the Committee agreed that for the patient described above, it would be clinically appropriate to implement risk-factor modification as required and observe. If such a patient had ongoing symptoms, or if the GP was concerned, the patient could be referred to a cardiologist, who could then order a CTCA if clinically appropriate.
  • ΔThe suggestion that calcium scoring and CTCA may be more appropriate gatekeepers.
    • Calcium scoring was proposed as a lower cost gatekeeper than EST, as recommended in the 2010 NICE guidelines. It was stated that there is a risk that a patient may have a negative EST but an elevated calcium score, as could also occur with negative functional studies. Such a patient may feel falsely reassured, leading to a lack of risk-factor modification and subsequent increased risk of adverse outcomes. The Committee acknowledged this, but felt that calcium scoring alone was an inappropriate gatekeeper because of its inability to detect non-calcified coronary lesions. Most members agreed that CTCA may soon become the preferred first-line investigation for suspected CAD, noting that there is some evidence that CTCA used in this way improves outcomes compared to the use of all forms of stress testing as the gatekeeper (22). However, evidence for CTCA is still emerging, and the current MBS fee of $700 is significantly higher than the fees for EST or stress echo. It was noted that the costs of performing CTCA may decrease to a level where it becomes a cost-effective solution.
  • ΔThe risk of cost increase.
    • The recommendation to use EST as the gatekeeper for low-risk patients is intended to reduce low-value functional imaging, which, aside from other benefits, would result in savings for CAD investigation. Some members of the Imaging Working Group raised concerns that this is dependent on resulting behaviour change among clinicians. If the majority of patients currently receiving functional imaging simply receive an additional preceding EST that is loosely interpreted as equivocal, they would then proceed on to the same service patterns that currently exist, or to even higher rates of downstream investigation, resulting in a significant increase in cost. Based on the available evidence, however, the majority of patients in this low-risk group (around 66–75 per cent) will have a negative EST (4,5) and would hence avoid subsequent investigations. The Committee noted that costings would be performed on the recommendation, but members who expressed this concern felt that a more detailed evaluation, such as that undertaken by the MSAC, would be a more appropriate level of analysis.
  • ΔConcern that this requirement would negatively affect patients from remote areas.
    • Questions were raised about the impact on patients who may travel long distances to access services. If such a patient travelled for an EST, which was then found to be positive, would they have to return on another day for functional imaging? If CTCA was unavailable, would a high-risk patient be required to have EST as a first-line investigation?
    • It was noted that if a provider felt that a patient was likely to require a stress echo but did not meet the criteria, he or she could perform limited ‘safety’ baseline and pre-stress echo views prior to the EST commencing. Should the EST be negative, the provider would not be able to charge for the stress echo. If the test was positive or indeterminate (DTS less than +5), the remainder of the stress echo could be performed and the service billed at the higher stress echo rebate. It would be inappropriate to bill for both the EST and the stress echo in this instance as the stress echo included the EST. However, if the patient had a positive or equivocal EST and was then slotted into an available space later the same day and underwent a full stress echo, including re-stressing, a rebate would be claimable for both services.
    • In response to these concerns, the Committee agreed that steps should be taken to ensure patients from regional and remote areas are not disadvantaged. It therefore agreed that functional imaging should be available as a first-line investigation alongside CTCA for patients with an Australian Absolute risk of greater than 10 per cent over five years.
  • ΔClarity on the definition of typical versus atypical angina.
    • The Committee agreed that the definition for typical angina should be adopted from the NICE guidelines. The guidelines list three features of angina pain:
      • Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms.
      • Precipitated by physical exertion.
      • Relieved by rest or Glyceryl trinitrate (GTN) within about five minutes.
    • If all three features are present, pain is defined as typical angina. If two or less features are present, pain is defined as atypical/uncertain symptoms.

Endorsement

The Imaging Working Group endorsed this recommendation. It passed with seven in favour, three opposed and one abstaining.

  • ΔDr Barry Elison – Against: Felt that the published literature supporting EST was not sufficiently powerful or recent. In addition, calcium scoring was felt to be a more effective and lower cost service to recommend as a gatekeeper.
  • ΔDr Geoff Evans – Against: Concerned that EST evidence is derived from low risk populations and is not objectively applicable to many rural/regional communities which are known to have higher disease prevalence. Supported recommendation for EST and DTS in clinically low-risk patients. Concerned restrictions may complicate rural services delivery and questioned predictive value of the Australian Absolute risk score in high disease prevalence populations.
  • ΔDr David Prior – Against: Agreed that considering EST as the first-line investigation is a good idea, but felt that making this a requirement (which does not take into account individual patient and local area conditions) was too strong a recommendation.
  • ΔDr Walid Jammal – Abstained: Supports EST be used in low risk patients, but abstained due to concerns about the potential for significant cost increases, as well as the validity and detail of the evidence which has been used to inform the recommendations. Supports a full HTA and MSAC assessment of the recommendations.

The Committee endorsed this recommendation unanimously.

4.5 Stress echo

Current item descriptors and MBS data from FY 2014/15
Item 55116 – Schedule fee: $261.65 Services: 243,163     Total Benefits: $54,370,194     Average annual growth: 12.2% Exercise stress echocardiography performed in conjunction with item 11712: (a) with: (i) two-dimensional recordings before exercise (baseline) from at least 3 acoustic windows; and (ii) matching recordings from the same windows at, or immediately after, peak exercise; and (iii) recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and (b) not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R)
Item 55117 – Schedule fee: $261.65 Services: 8,793     Total Benefits: $2,041,809     Average annual growth: 7.5% Pharmacological stress echocardiography performed in conjunction with item 11712: (a) with: (i) two-dimensional recordings before drug infusion (baseline) from at least 3 acoustic windows; and (ii) matching recordings from the same windows at least twice during drug infusion, including a recording at the peak drug dose; and (iii) recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and (b) not being a service associated with a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R)

Public data from 2014-15 (Department of Human Services)

Recommendation 4
  • ΔChange items 55116 and 55117 for stress echo to reflect a focused stress echo study for appropriate indications, as a complete medical service including EST.
    • Item 55116A: Focused exercise stress echo with limited structural baseline echo.
    • Item 55117A: Focused pharmacological stress echo with limited structural baseline echo.
    • Item 55116C: Exercise stress echo with complete structural baseline echo.
    • Item 55117C: Pharmacological stress echo with complete structural baseline echo.
    • Item 55116X: Repeat focused exercise/pharma stress echo with limited baseline due to change in clinical presentation post revascularisation.
    • Item 55116Y: Urgent stress echo with limited structural baseline echo performed within 4 weeks of a complete structural echo.
    • Item 55117B: Pharmacological stress echo performed within 4 weeks of failed exercise stress echo.

The descriptors and explanatory notes for these items are presented on the following pages.

Item 55116A

Exercise stress echocardiography, focused stress study with limited structural baseline echo performed by an appropriately trained provider for:

  • (a)Symptoms possibly related to cardiac ischaemia in patients who have one of:
    • i.An exercise stress test with a Duke Treadmill Score of less than +5; or
    • ii.An uninterpretable ECG which precludes exercise stress testing; or
    • iii.Typical angina meeting all three NICE criteria (see explanatory note); or
    • iv.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years.
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

Minimum requirements for testing are:

  • (a)Two-dimensional recordings before exercise (baseline) from at least 2 acoustic windows; and
  • (b)Matching recordings at or immediately after peak exercise, which include at least: parasternal short and long axis views, and apical 4-chamber, 2 chamber and long axis views; and
  • (c)Recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and
  • (d)The continuous attendance of a healthcare provider trained in cardiopulmonary resuscitation for the duration of the procedure, and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. Performed on premises equipped with standard resuscitation equipment and defibrillator; and
  • (e)Resting ECG and continuous multi-channel ECG monitoring and recording during stress; and
  • (f)With or without continuous blood pressure monitoring and the recording of other parameters; and
  • (g)Formal report, including relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.

If the minimum requirements for views or recordings in criteria (a) and (b) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study. Claimable once in any 2 year period including services of 55117A-C, 55116B, 55116X and 55116Y. Not claimable within 4 weeks of a service for items 5511A-D or 5511F.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

Appropriately trained means a provider that meets the level 2 requirements for stress echo as described in the CSANZ Guidelines for Training and Performance in Adult Echocardiography, or an equivalent training standard.

A complete echo includes any of items 55116C, 55117C, 5511A-D or 5511F.

[Surgical risk information as shown in Table 4]

Item 55117A

Pharmacological stress echocardiography, focused stress study with limited structural baseline echo performed by an appropriately trained provider for:

  • (a)Symptoms possibly related to cardiac ischaemia in patients who have one of:
    • i.An exercise stress test with a Duke Treadmill Score of less than +5; or
    • ii.An uninterpretable ECG or other condition which precludes exercise stress testing; or
    • iii.Typical angina meeting all three NICE criteria (see explanatory note); or
    • iv.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years.
  • (b)Known CAD, with symptom evolution since the previous functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

Minimum requirements for testing are:

  • (a)Two-dimensional recordings before drug infusion (baseline) from at least 2 acoustic windows; and
  • (b)Matching recordings at least twice during drug infusion, including a recording at the peak drug dose, which include at least: parasternal short and long axis views, and apical 4-chamber, 2 chamber and long axis views; and
  • (c)Recordings on digital media with equipment permitting display of baseline and matching peak images on the same screen; and
  • (d)The continuous attendance of a healthcare provider trained in cardiopulmonary resuscitation for the duration of the procedure, and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. Performed on premises equipped with standard resuscitation equipment and defibrillator; and
  • (e)Resting ECG and continuous multi-channel ECG monitoring and recording during stress; and
  • (f)With or without continuous blood pressure monitoring and the recording of other parameters; and
  • (g)Formal report, including relevant measurements and documentation of how the indication requirements of the descriptor were met. Separate from any letter(s) to the referrer, provided to the patient’s preferred general practitioner and/or the referring practitioner and images to be provided upon request to other clinicians with patient consent.

If the minimum requirements for views or recordings in criteria (a) and (b) are not met, the report must include documentation of which views were not obtained, the reason for this and any clinical implications. The service is not claimable if the views obtained are inadequate to be considered a diagnostic study. Claimable once in any 2 year period including services of 55117A-C, 55116B, 55116X and 55116Y. Not claimable within 4 weeks of a service for items 5511A-D, or 5511F.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

Appropriately trained means a provider that meets the level 2 requirements for stress echo as described in the CSANZ Guidelines for Training and Performance in Adult Echocardiography, or an equivalent training standard.

A complete echo includes any of items 55116C, 55117C, 5511A-D or 5511F.

[Surgical risk information as shown in Table 4]

Item 55116C

Exercise stress echocardiography, stress study and complete structural echocardiogram performed by an appropriately trained provider.

This service must meet all the requirements for a stress echo (item 55116A) AND all the requirements for a structural echo (item 5511A).

A single report must be provided documenting all required findings and measurements for each study. The report must clearly state the indication(s) which required both a complete structural and stress echo to be performed.

Claimable once in any 2 year period including services of 55116A, 55117A, 55117C, 55116X, 55116Y, 5511A-D, and 5511F.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: See explanatory notes for items 55117A and 5511A. Views taken to meet the requirements of item 5511A can be counted as pre-stress views as required by item 55116A.

Item 55117C

Pharmacological stress echocardiography, stress study and complete structural echocardiogram performed by an appropriately trained provider.

This service must meet all the requirements for item 55117A AND all the requirements for item 5511A.

A single report must be provided documenting all required findings and measurements for each study. The report must clearly state the indication(s) which required both a complete structural and stress echo to be performed.

Claimable once in any 2 year period including services of 55116A, 55117A, 55116C, 55116X, 55116Y, 5511A-D, and 5511F.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Explanatory notes: See explanatory notes for items 55117A and 5511A. Views taken to meet the requirements of item 5511A can be counted as pre-stress views as required by item 55117A.

Item 55116X

Repeat pharmacological or exercise stress echocardiography performed within 2 years of a previous stress echo study, where the patient has undergone a revascularisation procedure since the last stress echocardiogram and where all the requirements of either item 55116A or 55117A are met.

Claimable once in any 12-month period. Not claimable within 4 weeks of a service for item 5511A- F.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

  • ΔCreate a new item for urgent stress echo performed within 4 weeks of a structural echo (items 5511A-F) for a patient who develops a new indication requiring stress imaging.

Item 55116Y

Pharmacological or exercise stress echocardiogram performed within 4 weeks complete structural echo (items 5511A-F), where the patient has developed a new indication requiring additional stress imaging since the structural echo was performed.

The service must meet all the requirements of item 55116A or 55117A, and the report must clearly document the indication for the study.

Claimable once in any 2 year period including services of 55116A, 55117A, 55116C, 55117C, 55116X.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

  • ΔCreate a new item for repeat pharmacological stress echo following failed exercise stress echo. The proposed wording is outlined below.

Item 55117B

Pharmacological stress echocardiography performed within 4 weeks of a failed 55116A due to inadequate heart rate response in the initial study.

Meeting all the requirements for item 55117A; and

Claimable once in any 2 year period; and

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

  • ΔUpdate the explanatory notes for all items to reflect the clarified position of the MBS regarding co-claiming consultations with procedural and investigation items.
  • ΔRevise the Diagnostic Imaging Accreditation Scheme standards for stress echo items to align with the level 2 requirements of CSANZ or an equivalent acceptable standard.

Rationale

These recommendations focus on improving the value of the MBS and are based on the following observations.

  • ΔThe Committee noted that stress echos account for over $56 million in benefits annually, and that service volumes have grown at a rate of 12 per cent per year over the last five years. This represents unsustainable growth, which the Committee agreed goes beyond what could reasonably be attributed to clinical need. It was also noted that 70 per cent of stress echos appear to be referred by GPs (based on MBS data), which the Committee found surprising. This may reflect claiming or data-capture practices. For example, a cardiologist may have a referral on file from a GP and may bill all consults and stress echos, which are then recorded under that referral, although the stress echos may actually be self-determined by the cardiologist.
  • ΔAs mentioned above in Section 4.4, Medicare statistics show that stress echos and MPS lead to a revascularisation procedure over the next 18 months in only 1–3 per cent of cases (Table 2). Furthermore, there is marked variation in the rate of functional imaging per 100,000 population between states. For example, New South Wales’ rate of stress echos is more than three times the rates of South Australia and Western Australia (Figure 5). This variation is even more marked between Medicare locals, some of which have rates of stress echo up to 10 times higher than others (1). However, there is no evidence that this variation influences patient outcomes, and although there is almost certainly under-servicing in some areas, there is undoubtedly over-servicing in other areas.
  • ΔThe Committee noted that MBS data shows that 7 per cent of patients receive repeat services in a single year and as shown in Table 3, 20-45 per cent of patients are receiving annual or near annual stress echos—a practice not supported by evidence in the absence of clinical changes. The Committee recommended providing stress echos for patients with symptoms that suggest cardiac ischaemia or valvular pathology, or for patients at intermediate to high cardiovascular risk undergoing pre-operative assessment for high-risk surgery.
    Table 3: Number of years within a 5 year period in which a patient received at least 1 stress echo
    Years with at least 1 stress echo service, # Patients, # Proportion, %
    1 271 10%
    2 675 25%
    3 550 20%
    4 546 20%
    5 667 25%
    Total 2,718 100%

    Population of patients who received a cardiac investigation in June 2015, filtered for those who received at least 1 stress echo between financial years 2010/11 and 2014/15 inclusive. Cardiac investigation for this table includes: Stress echo (55116, 55117, 55122, 55123), CTCA (57360, 57361 ), Echo (55113, 55114, 55115, 55119, 55120, 55121), Angiography (ICA) (38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240, 38246, 59973, 59925, 59970, 59971), Exercise stress (11712), MPS (61302, 61306, 61651, 61652, 61653, 61303, 61307, 61654 ), FFR (38241). Unpublished data, extract based on date of service, 2009-10 to 2014-15 (Department of Health).

  • ΔThe Committee noted that pre-operative assessment is a common source of inappropriate use, and that the important determinant is the clinical risk of the patient(23,24). Pre-operative stress echo should only be performed in line with international guidelines, and it should be performed in patients with functional capacity of less than four METs (metabolic equivalents), where the surgery is intermediate to high risk (Table 4), and where the patient has at least one clinical risk factor including: ischaemic heart disease (angina pectoris and/or previous myocardial infarction); heart failure; stroke or transient ischaemic attack; renal dysfunction (serum creatinine >170umol/L or 2 mg/dL, or a creatinine clearance of <60 mL/min); or diabetes mellitus requiring insulin therapy (25).
    Table 4: Surgical risk estimate according to type of surgery or intervention (25)
    Low risk: < 1% Intermediate risk: 1–5% High risk: > 5%
    • ΔSuperficial surgery
    • ΔBreast
    • ΔDental
    • ΔEndocrine: thyroid
    • ΔReconstructive
    • ΔCarotid asymptomatic (CEA or CAS)
    • ΔGynaecology: minor
    • ΔOrthopaedic: minor (meniscectomy)
    • ΔUrological: minor (transurethral resection of the prostate)
    • ΔIntraperitoneal: splenectomy, hiatal hernia repair, cholecystectomy
    • ΔCarotid symptomatic (CEA or CAS)
    • ΔPeripheral arterial angioplasty
    • ΔEndovascular aneurysm repair
    • ΔHead and neck surgery
    • ΔNeurological or orthopaedic: major (hip and spine surgery)
    • ΔUrological or gynaecological: major
    • ΔRenal transplant
    • ΔIntra-thoracic: non-major
    • ΔAortic and major vascular surgery
    • ΔOpen lower limb revascularisation or amputation or thromboembolectomy
    • ΔDuodeno-pancreatic surgery
    • ΔLiver resection, bile duct surgery
    • ΔOesophagectomy
    • ΔRepair of perforated bowel
    • ΔAdrenal resection
    • ΔTotal cystectomy
    • ΔPneumonectomy
    • ΔPulmonary or liver transplant
    CAS = carotid artery stenting; CEA = carotid endarterectomy. a Surgical risk estimate is a broad approximation of 30-day risk of cardiovascular death and myocardial infarction that takes into account only the specific surgical intervention, without considering the patient’s comorbidities.
  • ΔIn addition to refining the inclusion criteria, the Committee agreed that stress echos were clearly low value and should not be claimable for screening, patients who are asymptomatic and have a normal cardiac examination, or monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study (21,26).
  • ΔAlthough only a small proportion of patients received more than two stress echo services within a year, the Committee nonetheless agreed that this represented low-value use. It therefore recommended that patients should receive no more than one stress echo every two years except where revascularisation has been performed since the previous study. All stress echos after the first test should require symptom evolution or changes on cardiac examination since the last study.
  • ΔThe Committee noted that exercise stress echos are sometimes inconclusive if the patient does not reach an adequate heart rate (although this is uncommon). It is standard practice to cease rate control medications prior to a stress test, and to only attempt studies in a patient reasonably expected to be able to exercise sufficiently. However, there are occasions when this does not occur. For example, a patient who is instructed to cease his or her rate control medications may arrive on the day having continued to take them. In such instances, it was noted that providers may attempt the study anyway, acknowledging a high risk of failure. Patients may also have a positive study with signs of ischaemia despite a low heart rate, but if the study is negative without an adequate elevation in heart rate, the test is inconclusive. In such instances, the Committee agreed that it would be reasonable for a patient to return for a pharmacological stress echo or be referred for MPS. The majority of Committee members felt that it is inappropriate to claim for a second attempt at an exercise stress echo. The Committee therefore recommended creating a new item that allows a pharmacological stress echo to be performed in these instances, without counting towards the two-per-year claim restriction. This would have the same MBS fee as a standard pharmacological stress echo, as the equipment and time requirements are the same. These requirements were felt to be sufficient to prevent abuse of this item.
  • ΔCommittee members are aware that some providers currently perform only a limited baseline echo before stress echos while claiming the rebate for the stress echo item number (~$260) whilst there are other providers who perform a complete structural baseline echo and claim the same item. The Committee agreed this was not appropriate and that services of varying levels of comprehensiveness should have differentiated rebates.
  • ΔThe Committee agreed that the current items do not clearly outline what baseline elements are expected to be performed as part of the stress echo study. It agreed that the majority of patients only require a focused stress echo with limited structural baseline echo to screen for safety concerns. A complete structural baseline echo is not required for these patients and would be low value care. For the remaining patients, there are clinical circumstances where a full structural echo and stress echo on the same day is appropriate. As such, the Committee recommended that the current stress echo item be split into an item which includes only a limited ‘safety’ baseline echo, and an item which includes a complete structural echo. The Committee recommends a review be conducted of the relevant stress echo rebates with adjustments to reflect the proposed item structure. The Committee recommends such adjustments be at least cost neutral.
  • ΔThe Committee noted that some providers have patients attend for a standard structural echo (55113) on one day, and then return on a subsequent day for a stress echo. Figure 8 shows that this affects approximately 40,000 patients per year. The MBS currently restricts the same day co-claiming of stress echo and structural echo. The Committee agreed that a portion of this service splitting reflects appropriate use such as for patients which evolving indications, however a portion may also reflect misuse and circumvention of the co-claiming restriction. MBS data shows that some providers have up to 88% of their patients receiving a structural echo within 4 weeks prior to stress echo, while the median is less than 13% (9). It was agreed by the Committee that patients attending unnecessarily on multiple days is a low-value use of health resources and inconvenient for the patients. To address this issue, the Committee recommended extending the co-claiming restriction to four weeks. The Committee noted that addressing this unusual practice is a very good outcome of this review, as it improves services for patients and improves the value of the services provided.
  • ΔAcknowledging that there may be circumstances where a patient undergoes a standard echo and then in the following days or weeks develops new symptoms which indicate that a stress echo should be performed urgently. An item (55116Y) has been created to cater for this small population and it is expected that this will be a small proportion of a provider’s services and will require clear documentation of the indication for the urgent study. Similarly, there is a chance that a patient may need a standard echo within days or weeks of receiving a stress echo. The item for exceptional structural echos (5511F) could be used in these instances. MBS data shows that this occurs in fewer than 7% of patients receiving stress echos (9).
    Figure 8: Claims for standard echo services before or after stress echo
    Figure 8 shows claims for standard echo services before or after stress echo. The heading on the figure reads “Over 6 months 20,409 patients (17%) received a standard echo within 4 weeks prior to a stress echo. The figure shows this, and also shows that an additional 5% of patients (n=6,023) received a standard echo within 4 weeks after a stress echo. The data both before and after is broken down into time bands of same day, 1 day before/after, 2-7 days, 1-2 weeks, 2-4 weeks. The highest rates are in the 2-7 day band both before and after.

    Unpublished data, extract based on date of service and captures all stress echos over 6 months in 2014, the total number of patients is 123,495 (Department of Health). Echo items 5113, 55114, 55115, 55119, 55120, 55121. Stress echo items 55116, 55117, 55122, and 55123.

  • ΔTo reduce variability in the rebate patients receive, and to modernise and simplify the MBS, the Committee recommended that the stress echo items should be updated to include the EST component that is currently co-claimed. Figure 9 presents a simple bar graph to illustrate this amalgamation. Co-claiming data also showed that standard 12-lead ECGs were being co-claimed with this service. The Committee agreed that this was inappropriate, and that these ECGs should be included in the service where performed. Specialist consults were co-claimed with 48 per cent of ESTs and 27 per cent of pharmacological stress services. It is likely that these rates represent inappropriate co-claiming practices. The Committee recommended educating providers on the rules regarding co-claiming of consults with procedures and investigations, and that the MBS audit and compliance team routinely monitor for outliers.
    Figure 9: Indicative depiction of amalgamation of stress echo and EST fees based on the Committee’s recommendations
    Figure 9 is a bar graph that shows the indicative depiction of the amalgamation of stress echo and EST fees based on the Committee's recommendations. The graph shows that the current stress echo and EST fee is equal to the proposed stress echo fee.
  • ΔThe Committee discussed a number of additional ways to reduce low-value use of stress echos (particularly initial studies), including restrictions for low pre-test probability, normal CTCA, prior evidence of subclinical disease or uninterpretable ECGs. It was agreed that use for CAD-related indications within five years of a high-quality CTCA with a normal calcium score and no plaques should be restricted.
  • ΔThe Committee discussed the appropriateness of stress echo as a first-line investigation. It agreed that in low- or intermediate-risk patients, an EST should be the first-line investigation, and that no further investigations should be provided if that EST is normal. From a prognostic perspective, stress ECG is appropriate for reassuring patients with low or intermediate risk. For patients with ongoing symptoms or patients at high risk, referral to a cardiologist or physician is appropriate. Further discussion of this recommendation is outlined in Section 4.4.
  • ΔThe Committee noted that despite MBS requirements under the DIST, as well as accepted standards of good clinical practice, some practitioners are not providing formal reports for stress echos they perform. It was agreed that a formal report should be documented (separate from any letters), provided to the patient’s GP and referring provider (if applicable), and retained in line with DIST requirements. The Committee also noted that the quality of some studies was lower than would be expected of an appropriately trained provider. The Committee therefore recommended that the accreditation standards for stress echo items should be increased to align with the level 2 requirements for stress echo as stated in the CSANZ Guidelines for Training and Performance in Adult Echocardiography or an equivalent acceptable standard(11). Ensuring the skills and expertise of those performing these studies was viewed as a critical step towards ensuring that all services provide clinically useful, diagnostic quality information.

4.6 Myocardial perfusion scans

Due to their interconnectedness, the Committee considered MPS in conjunction with the other cardiac imaging modalities. The Committee has developed provisional recommendations regarding MPS for the consideration of the Diagnostic Imaging Clinical Committee (DICC) and their Nuclear Medicine Working Group (NMWG). These recommendations will be submitted to the DICC and NMWG for consideration as they formulate their own recommendations to the Taskforce. The recommendations will also be included in this Committee’s final report to the Taskforce as they are integral to the recommendations made for ICA, PCI and other investigations discussed in this report.

Current item descriptors and MBS data from FY 2014/15
Item 61302 – Schedule fee: $448.85 Services: 107      Total Benefits: $44,849      Average annual growth: 7.7% Single stress or rest myocardial perfusion study - planar imaging(R)
Item 61303 – Schedule fee: $565.30 Services: 6,630      Total Benefits: $3,484,260      Average annual growth: 17.4% Single stress or rest myocardial perfusion study - with single photon emission tomography and with planar imaging when undertaken (R)
Item 61306 – Schedule fee: $709.70 Services: 106      Total Benefits: $70,283      Average annual growth: 16.2% Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion - planar imaging (R)
Item 61307 – Schedule fee: $834.90 Services: 74,831      Total Benefits: $58,475,142      Average annual growth: -0.7% Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion - with single photon emission tomography and with planar imaging when undertaken (R)

Public data 2014-15 (Department of Human Services)

Recommendation 5.1
  • ΔSplit items 61302 and 61303 into separate rest and stress items and update the descriptors for all MPS items as set out below.
Recommendation 5.2
  • ΔRevise the schedule fee for the single rest items such that the combined fee for separate rest and stress items is equal to the fee for the combined item.

Item 61302A

Single rest myocardial perfusion study - planar imaging, performed for:

  • (a)Symptoms possibly related to cardiac ischaemia in a patient who meets both criteria below:
    • i.Have at least one of:
      • A.An exercise stress test with a Duke Treadmill Score of less than +5; or
      • B.An uninterpretable ECG or other condition which precludes exercise stress testing; or
      • C.Typical angina meeting all three NICE criteria (see explanatory note); or
      • D.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years; and
    • ii.Meet at least one of the following criteria:
      • A.Body habitus or other physical condition (including heart rhythm disturbance) such that stress echo is unlikely to provide adequate information; or
      • B.Unable to exercise; or
      • C.Is unable to access a stress echo due to distance, cost or clinically unacceptable wait times; or
      • D.Has had a failed stress echo; or
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

With documentation in the report of how the indication requirements of the descriptor were met.

A myocardial perfusion study is claimable once every 2 years, consisting of 1 combined study or 1 rest study and 1 stress study, whether performed with planar or SPECT imaging (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

For the purposes of criteria (a) ii C, cost can include upfront costs or out-of-pocket costs which may create an economic barrier to accessing stress echo services.

[Surgical risk information as shown in Table 4]

Item 61302B

Single stress myocardial perfusion study - planar imaging, performed for:

  • (a)Symptoms possibly related to cardiac ischaemia in a patient who meets both criteria below:
    • i.Have at least one of:
      • A.An exercise stress test with a Duke Treadmill Score of less than +5; or
      • B.An uninterpretable ECG or other condition which precludes exercise stress testing; or
      • C.Typical angina meeting all three NICE criteria (see explanatory note); or
      • D.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years; and
    • ii.Meet at least one of the following criteria:
      • A.Body habitus or other physical condition (including heart rhythm disturbance) such that stress echo is unlikely to provide adequate information; or
      • B.Unable to exercise; or
      • C.Is unable to access a stress echo due to distance, cost or clinically unacceptable wait times; or
      • D.Has had a failed stress echo; or
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

Including:

  • (a)Exercise or pharmacological stress; and
  • (b)The continuous attendance of a healthcare provider trained in cardiopulmonary resuscitation for the duration of the procedure, and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. Performed on premises equipped with standard resuscitation equipment and defibrillator; and
  • (c)With or without continuous blood pressure monitoring and the recording of other parameters.

With documentation in the report of how the indication requirements of the descriptor were met.

A myocardial perfusion study is claimable once every 2 years, consisting of 1 combined study or 1 rest study and 1 stress study, whether performed with planar or SPECT imaging (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

For the purposes of criteria (a) ii C, cost can include upfront costs or out-of-pocket costs which may create an economic barrier to accessing stress echo services.

[Surgical risk information as shown in Table 4]

Item 61303A

Single rest myocardial perfusion study - with single photon emission tomography and with planar imaging when undertaken, performed for:

  • (a)Symptoms possibly related to cardiac ischaemia in a patient who meets both criteria below:
    • i.Have at least one of:
      • A.An exercise stress test with a Duke Treadmill Score of less than +5; or
      • B.An uninterpretable ECG or other condition which precludes exercise stress testing; or
      • C.Typical angina meeting all three NICE criteria (see explanatory note); or
      • D.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years; and
    • ii.Meet at least one of the following criteria:
      • A.Body habitus or other physical condition (including heart rhythm disturbance) such that stress echo is unlikely to provide adequate information; or
      • B.Unable to exercise; or
      • C.Is unable to access a stress echo due to distance, cost or clinically unacceptable wait times; or
      • D.Has had a failed stress echo; or
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

With documentation in the report of how the indication requirements of the descriptor were met.

A myocardial perfusion study is claimable once every 2 years, consisting of 1 combined study or 1 rest study and 1 stress study, whether performed with planar or SPECT imaging (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

For the purposes of criteria (a) ii C, cost can include upfront costs or out-of-pocket costs which may create an economic barrier to accessing stress echo services.

Surgical risk information as shown in Table 4]

Item 61303B

Single stress myocardial perfusion study - with single photon emission tomography and with planar imaging when undertaken, performed for:

  • (a)Symptoms possibly related to cardiac ischaemia in a patient who meets both criteria below:
    • i.Have at least one of:
      • A.An exercise stress test with a Duke Treadmill Score of less than +5; or
      • B.An uninterpretable ECG or other condition which precludes exercise stress testing; or
      • C.Typical angina meeting all three NICE criteria (see explanatory note); or
      • D.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years; and
    • ii.Meet at least one of the following criteria:
      • A.Body habitus or other physical condition (including heart rhythm disturbance) such that stress echo is unlikely to provide adequate information; or
      • B.Unable to exercise; or
      • C.Is unable to access a stress echo due to distance, cost or clinically unacceptable wait times; or
      • D.Has had a failed stress echo; or
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

Including:

  • (a)Exercise or pharmacological stress; and
  • (b)The continuous attendance of a healthcare provider trained in cardiopulmonary resuscitation for the duration of the procedure, and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. Performed on premises equipped with standard resuscitation equipment and defibrillator; and
  • (c)With or without continuous blood pressure monitoring and the recording of other parameters.

With documentation in the report of how the indication requirements of the descriptor were met.

A myocardial perfusion study is claimable once every 2 years, consisting of 1 combined study or 1 rest study and 1 stress study, whether performed with planar or SPECT imaging (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

For the purposes of criteria (a) ii C, cost can include upfront costs or out-of-pocket costs which may create an economic barrier to accessing stress echo services.

[Surgical risk information as shown in Table 4]

Item 61306A

Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion - planar imaging, performed for:

  • (a)Symptoms possibly related to cardiac ischaemia in a patient who meets both criteria below:
    • i.Have at least one of:
      • A.An exercise stress test with a Duke Treadmill Score of less than +5; or
      • B.An uninterpretable ECG or other condition which precludes exercise stress testing; or
      • C.Typical angina meeting all three NICE criteria (see explanatory note); or
      • D.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years; and
    • ii.Meet at least one of the following criteria:
      • A.Body habitus or other physical condition (including heart rhythm disturbance) such that stress echo is unlikely to provide adequate information; or
      • B.Unable to exercise; or
      • C.Is unable to access a stress echo due to distance, cost or clinically unacceptable wait times; or
      • D.Has had a failed stress echo; or
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

Including:

  • (a)Exercise or pharmacological stress; and
  • (b)The continuous attendance of a healthcare provider trained in cardiopulmonary resuscitation for the duration of the procedure, and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. Performed on premises equipped with standard resuscitation equipment and defibrillator; and
  • (c)With or without continuous blood pressure monitoring and the recording of other parameters.

With documentation in the report of how the indication requirements of the descriptor were met.

A myocardial perfusion study is claimable once every 2 years, consisting of 1 combined study or 1 rest study and 1 stress study, whether performed with planar or SPECT imaging (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

For the purposes of criteria (a) ii C, cost can include upfront costs or out-of-pocket costs which may create an economic barrier to accessing stress echo services.

[Surgical risk information as shown in Table 4]

Item 61307A

Combined stress and rest, stress and re-injection or rest and redistribution myocardial perfusion study, including delayed imaging or re-injection protocol on a subsequent occasion - with single photon emission tomography and with planar imaging when undertaken, performed for:

  • (a)Symptoms possibly related to cardiac ischaemia in a patient who meets both criteria below:
    • i.Have at least one of:
      • A.An exercise stress test with a Duke Treadmill Score of less than +5; or
      • B.An uninterpretable ECG or other condition which precludes exercise stress testing; or
      • C.Typical angina meeting all three NICE criteria (see explanatory note); or
      • D.Atypical or uncertain symptoms and an Australian Absolute Risk Score of >10% for cardiovascular events within 5 years; and
    • ii.Meet at least one of the following criteria:
      • A.Body habitus or other physical condition (including heart rhythm disturbance) such that stress echo is unlikely to provide adequate information; or
      • B.Unable to exercise; or
      • C.Is unable to access a stress echo due to distance, cost or clinically unacceptable wait times; or
      • D.Has had a failed stress echo; or
  • (b)Known CAD, with symptom evolution since the functional imaging study; or
  • (c)Assessment of non-CAD related disease in line with clinical guidelines; or
  • (d)Pre-operative assessment of a patient with functional capacity of <4 METs where the surgery is intermediate to high risk (see explanatory notes) and the patient has at least one of: (a) ischaemic heart disease or previous myocardial infarction; (b) heart failure; (c) stroke or transient ischaemic attack; (d) renal dysfunction (serum creatinine >170umol/L or 2 mg/dL or a creatinine clearance of <60 mL/min); or (e) diabetes mellitus requiring insulin therapy.

Not claimable for (i) screening; or (ii) patients who are asymptomatic and have a normal cardiac examination; or (iii) monitoring or routine surveillance of known disease in the absence of symptom evolution or changes on cardiac examination since the last study; or (iv) coronary artery disease related indications within 5 years of a high quality CTCA with a normal calcium score and no plaques.

Including:

  • (a)Exercise or pharmacological stress; and
  • (b)The continuous attendance of a healthcare provider trained in cardiopulmonary resuscitation for the duration of the procedure, and with a second trained provider either present for the duration of the procedure or able to respond immediately with suitable emergency call mechanisms in place. Performed on premises equipped with standard resuscitation equipment and defibrillator; and
  • (c)With or without continuous blood pressure monitoring and the recording of other parameters.

With documentation in the report of how the indication requirements of the descriptor were met.

A myocardial perfusion study is claimable once every 2 years, consisting of 1 combined study or 1 rest study and 1 stress study, whether performed with planar or SPECT imaging (R).

Explanatory notes: Typical angina is defined as meeting all three of the following: 1) constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms; AND 2) precipitated by physical exertion; AND 3) relieved by rest or GTN within about 5 minutes. Without meeting all three criteria, symptoms should be considered atypical/uncertain.

A calcium score of zero is normal and clinician judgement should be applied for scores of 0–10.

For the purposes of criteria (a) ii C, cost can include upfront costs or out-of-pocket costs which may create an economic barrier to accessing stress echo services.

[Surgical risk information as shown in Table 4]

  • ΔCreate a new item for repeat MPS within 2 years with intervening revascularisation
  • ΔConduct a GP education campaign focused on the appropriate use of cardiac imaging modalities and investigations, including EST, stress echo, MPS, ICA and CTCA.
  • ΔAdd the following explanatory note to the items for stress echo and MPS:

Explanatory note: In the majority of cases, both stress echo and MPS provide equivalent information. Consideration should be given to the cost and radiation burden of the tests when determining the appropriate modality for a patient, the patient should be fully informed and involved in this decision. It should also be noted that stress echo involves no radiation and that on average; CTCA has a considerably lower radiation dose than MPS or invasive coronary angiography.

Item 6130X

Repeat combined rest and stress myocardial perfusion study performed within 2 years of a previous study, where the patient has undergone a revascularisation procedure since the last myocardial perfusion study and where all the requirements of item 61307 are met.

Claimable once in any 12-month period.

Not being a service associated with a service to which items 11700–11702 or 11712 apply; or a service to which an item in Subgroup 1 (except item 55054) or 3, or another item in this subgroup (except items 55118 and 55130), applies (R).

Rationale

These recommendations focus on improving the value of the MBS and are based on the following observations.

  • ΔAlthough MPS represent only 5 per cent of cardiac imaging services and have a relatively flat growth rate of less than 1 per cent per year, they account for 17 per cent of the annual MBS benefits at $62 million per year (Figure 10). The Committee therefore felt it prudent to consider where the value of MPS services could be improved.
    Figure 10: Basic MBS data on the scope of the Cardiac Imaging Working Group
    Figure 10 shows two pie charts and other basic MBS data. The scope included 11 items which represents $364.9 million in benefits and over 1.7 million services, growth has been 6% per year. The first pie chart shows the percentage of total Imaging services in 2014-15 by modality and another shows the percentage of total Imaging benefits in 2014-15 by modality. Echo has the highest percentage from both the total Imaging services and benefits at 53% and 50% respectively. Second highest is Exercise stress test at 27% and 17% respectively. Stress echo accounts for 15% of both services and benefits, while MPS accounts for only 5% of services but 17% of benefits. TOE has the lowest percentage for both services and benefits at 1%.

    Data is by date of service. Unpublished data (Department of Health). Echo includes 55113, 55114, and 55115, EST 11712, Stress Echo 55116, 55117, MPS 61302, 61303, 61306, 61307, and TOE 55118

  • ΔThe Committee strongly agreed that, as with other functional studies, it is not appropriate to use MPS as screening tests for asymptomatic patients, for routine annual investigation of patients with known disease, or in the absence of symptom evolution or changes on cardiac examination. As discussed in the EST and stress echo sections of this report, the Committee agreed that the first-line investigation for patients with atypical chest pain or other symptoms possibly due to CAD and an Australian Absolute risk score of less than 10 per cent over five years should be EST. The indications for stress echo and MPS remain equivalent.
  • ΔIt was acknowledged that for certain high-risk patients who are being considered for a major operation, it may be appropriate to perform a cardiac functional study such as MPS to exclude significant undiagnosed CAD, which can significantly increase the mortality risk of the procedure.
  • ΔIt was agreed that MPS are intended for symptomatic patients with low to intermediate or intermediate risk of CAD, and that they should not be performed for patients with a low pre-test probability. With regards to stress echo, the Committee recommended that EST should be used as the first-line investigation for atypical chest pain. MPS should only be used as the first-line investigation for a patient with atypical chest pain if he or she is unable to exercise, or has an uninterpretable ECG, or has an equivocal or indeterminate EST.
  • ΔFor suspected CAD, the Committee agreed that stress echo should be the preferred investigation over MPS except for patients: who are unable to perform a stress echo; who are unable to reasonably access a stress echo; or in whom a stress echo may be technically unfeasible (for example, due to body habitus). The Committee considered that for most patients with suspected CAD, stress echo and MPS provide clinically equivalent information, and where the information is equivalent stress echo should be preferred as it does not involve radiation exposure. Stress echo is also likely to be a lower cost investigation.
  • ΔThe Committee noted that for known CAD, MPS and stress echo may provide different clinical information and as such, this should remain at the discretion of the referring provider.
  • ΔWhen considering the radiation exposure, the Committee noted that MPS are generally accepted as safe and appropriate tests for investigating suspected ischaemic heart disease. It was noted that the published average radiation dose for combined rest and stress MPS has declined from 20mSv to 12mSv using technetium-99m-labelled agents(27). As a comparison, a diagnostic ICA (7mSv), a CTCA (1-4mSv) or over twice the average annual non-medical radiation exposure(27-29). The Nuclear Medicine Working Group provided expert advice that average MPS radiation doses in Australia are significantly lower than published literature, with modern imaging protocols and technology permitting effective radiation doses of less than 3mSv. While significantly lower than published figures, this is not an insignificant dose of radiation, equivalent to approximately 150 chest X-rays (at 0.02mSv each)(28).
  • ΔThe Committee agreed that even if MPS and stress echo are agreed to be of equal cost and clinical utility, stress echo does not involve a radiation burden and so, where available and reasonably possible, it should be the first line investigation(30).
  • ΔThe relative cost of each service was considered and is discussed in detail in Section 4.7.
  • ΔIt was noted that there is inadequate access to stress echo services in many regional areas, including prolonged wait times. MPS are more readily available, and they provide additional access to functional cardiac imaging. This is supported by MBS data, which shows that MPS have higher per-capita usage in regional areas—a trend not seen in other cardiac imaging items (Figure 11). This was flagged as a concern for consumers, given that MPS entail radiation exposure, although the radiation burden is low (as discussed above) and is decreasing over time(27). There is also a difference in terms of out-of-pocket costs, which could affect the consumer: over 95 per cent of MPS studies are bulk-billed, compared to 70 per cent of stress echos. This may be because a large proportion of nuclear medicine studies are provided by public hospital facilities, while stress echos are performed widely in both private and public settings.
  • ΔThe Committee agreed that the local access implications—particularly in regional or remote areas or areas with a lower socioeconomic status—may lead a referrer to request an MPS even in a patient where a stress echo (with no radiation burden) would be clinically appropriate. It is important for referring clinicians to have a clear understanding of the risks and benefits of various cardiac investigation options when making such decisions(30). The Committee recommended that a GP education campaign be undertaken regarding the appropriate use of cardiac imaging modalities and other cardiac investigations.
  • ΔFrom a consumer perspective, use of MPS over stress echo where clinically equivalent may be appropriate if patients are fully informed about the radiation exposure and risks associated with this. The Committee recommended amending the explanatory notes for all stress echo and MPS items to encourage requestors to consider the cost and radiation exposure associated with various tests when determining, with the patient, the most appropriate modality. A similar explanatory note could be applied to anatomical diagnostics such as CTCA and ICA, as well as other investigations involving radiation exposure, however a radiation free alternative is less clear in these situations so this is not currently recommended.
  • ΔWhile it would be preferable for all patients to have easy access to stress echo, this is unlikely to be achieved in the immediate term. As such, the Committee recommended that access to MPS as a first line investigation is retained where a patient is unable to access stress echo due to distance, out-of-pocket cost or wait times for stress echos in their area.
    Figure 11: Geographical variation in MPS services
    Figure 11 is a bar graph that shows geographical variation in MPS services per capita. There are two bar graphs, one that depicts state-based variation and another for rurality based variation. State-based variations shows a 2-3 fold variation. NSW, VIC and QLD are the highest at 447, 358 and 383 services per 100.000 population respectively. TAS is 262 and SA, WA, NT and ACT are all under 200. Rurality-based variations shows  that Inner regional has the highest per capita service volume at 497.0. Major citis, outer regional, remote and very remote are under 340 services per 100,000 population.

    Unpublished data by date of service for Medicare claims processed between July 1 2014 and April 30 2016 extracted on 20 June 2016 (Department of Health). Remoteness Area classes are based on ARIA. Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file. MPS items 61303, 61307, 61654, 61302, 61306, 61651, 61652, and 61653.

  • ΔThe Committee discussed the issue of repeat MPS, which account for 4 per cent of patients each year, and 19 per cent over five years. Although normal MPS provide a ‘warranty’ for three years, repeat studies may be appropriate if symptoms change significantly. It was therefore agreed that up to two studies within 12 months would be appropriate, particularly (but not exclusively) for patients who undergo revascularisation between studies. It is unlikely that this would result in any significant access restrictions. As mentioned previously, studies should only be performed if there has been symptom evolution since the last study.
  • ΔThe Committee discussed co-claiming and noted that co-claiming MPS with consults should already be excluded under the current items. Nuclear medicine item numbers include a consultation element, and this is reflected in the current schedule fees. The Committee recommended ensuring diligent application of this rule.
  • ΔThe Committee considered creating MPS as a complete medical service, but it felt that although CT attenuation is appropriate clinical practice, it is not currently a required component of services. Furthermore, including it may mean that many centres are unable to perform the study due to a lack of appropriate equipment, which may result in access issues in rural areas. The Committee agreed that any co-claiming with EST should be included in the schedule fee, and that co-claiming of item 11712 should be restricted.
  • ΔThe Committee discussed the lower volume planar items and felt that these should be retained as distinct services based on advice that these items may be used when there is a technical failure of the SPECT equipment. The planar films allow the capture of clinically relevant information (although the information is of lower value than SPECT images), which prevents the patient from having to undergo a complete repeat study. The Committee felt that planar films reflect acceptable contemporary practice in this context. The Committee received advice from the NMWG of the DICC that they intend to remove planar items. The Committee defers to the DICC on this matter and would not object to such a recommendation applying to the relevant MPS items.
  • ΔThe Committee noted that there is currently an incentive to split an MPS over two days to attract a higher remuneration (2 x $565.30 versus 1 x $834.90). Although the split services represent only 8 per cent of studies, this has increased from 4 per cent of studies over the last five years. Allowing the service to be run over multiple days does not cause harm to patients and is appropriate in certain situations such as for obese patients or those with a low probability of CAD(31). However, it is (at the very least) inconvenient for many patients. To remove the financial incentive for this, the Committee recommended revising the schedule fees for items 61302 and 61303 such that the single stress item (i.e. 61303B) retain the current single rebate ($565.30 for SPECT item). The single rest item would be set as the relevant combined item less the stress rebate (i.e. SPECT single rest study would be $834.90 less $565.30 resulting in a fee of $269.60). The stress item would then be increased by the EST item rebate amount if merged into a complete medical service as described above.
  • ΔThe Nuclear Medicine Working Group of the Diagnostic Imaging Clinical Committee may consider recommending the removal of the planar item numbers. These have been retained in this Report, however if there is a recommendation made to remove planar item numbers, the proposed items 61302A, 61302B and 61306A would not be required.

4.7 Cost comparison of stress imaging modalities

Recommendation 6
  • ΔResearch focused on understanding the cost-effectiveness of cardiac investigations and interventions in the Australian context should be undertaken.

Rationale

These recommendations focus on encouraging best-practice care and improving the value of the MBS. They are based on the following observations.

  • ΔThe Committee agreed that stress echo and MPS provide clinically equivalent information related to myocardial ischaemia for the majority of patients, offering similar sensitivity and specificity (32,33). However, MPS is accepted as more clinically appropriate for certain indications, such as assessing the extent of the ischaemic burden of known CAD (where it is clinically superior) and investigating patients who are unable to have a stress echo (for example, due to obesity) (34). Similarly stress echo is more clinically appropriate in other situations, such as where visualisation of the valves is clinically relevant to the patient.
  • ΔThe MBS items for both MPS and stress echo are co-claimed with EST when providing a service. As a result, the standard MBS rebate (based on current items) for stress echo is $413.80 ($152.15 for EST + $261.65 for stress echo), and the standard rebate for MPS is $987.05 ($152.15 for EST + 834.90 for MPS item 61307, which accounts for 92 per cent of services) (1). The schedule fee for MPS is approximately 2.4 times higher than the fee for stress echo.
  • ΔIf one service costs the health system significantly more than the other service but provides the same clinical information, this may indicate low-value care. Three options are available in this situation, all of which were considered by the Committee. Figure 12 lists some of advantages and disadvantages of each option, based on the fact that MPS have a higher rebate than stress echoes. The Committee agreed that should stress echoes have a higher cumulative cost, the same options would be available but the advantages and disadvantages of these options may change.

    The three options included:

    • 1)Accepting the higher cost of MPS and making no change.
    • 2)Making changes to access, leading to preferential use of the lower cost service where clinically appropriate.
    • 3)Reducing the cost (rebate) of the higher cost service to reduce the value differential.
  • ΔAdditional options—such as placing restrictions on providers who can refer for certain services—can have inequitable impacts on patients from rural areas and were therefore not considered in detail.
    Figure 12: Potential recommendations if cost differential is found
    Figure 12 shows the potential recommendations if cost differential is found between MPS and stress echo. The figure shows the Pros and Cons are for three scenarios: A. No change – accept the higher cost for the same clinical outcome; B. Change access – make stress echo the 1st line and MPS 2nd line available when clinically necessary; and C. Change cost – Reduce the rebate for MPS to the input costs or to the same level as stress echo. The pros for option A are that patients have access to MPS as 1st line, possibly shorter wait times or lower out-of-pocket costs in some areas. Cons for option A are higher cost to the health system without added value, this cost is potentially significant. The pros for option B are that the rebates for both services remains unchanged and the value of functional imaging is improved. The cons for option B are that patients may have higher out-of-pocket costs in some areas and may have to wait longer for imaging in some areas, with patients in regional areas more likely to be affected based on current service distributions. Pros for option C are that patients have access to MPS 1st line, possibly shorter wait times and the value of MPs is improved. The cons for option C are that a lower rebate may increase out-of-pocket costs, if the rebate is lower than the input costs of the service it may cease to be offered in some areas, and this may disadvantage patients who clinically need MPS services and are not suitable for stress echo.

    1 Changing which practitioners can refer is also an option, but is generally not desirable for various reasons.
    2 Radiation burden of MPS is not listed as it is generally considered a very low dose (note OOP means out-of-pocket costs)

  • ΔThe Committee identified three questions that would influence its final recommendation.
    • Is there a cost difference? If so, how significant is the impact on the health system?
        • This involved considering both the service itself and a more comprehensive view over time to capture impacts on claim patterns for other services.
    • To what extent will the changes affect patients?
      • This involved considering positive and negative impacts over the short and long term.
    • To what extent do the options align with the principles of the MBS?
      • This involved considering whether schedule fees should reflect the input costs or the clinical value of the service provided.
  • ΔThe Committee agreed that a cost-comparison analysis should be performed, comparing the cumulative cost of services over a defined period for patients receiving either MPS or stress echo as their primary investigation. This analysis was performed, and patients were eligible for inclusion in this analysis if they received either a stress echo or MPS in the first quarter of 2015 (the ‘trigger’). Patients were excluded if they had received a stress echo, MPS, ICA, CTCA or EST in the six weeks prior to the first quarter of 2015. The analysis included 59,322 patients for stress echo and 17,615 patients for MPS. The demographics of both the total population (Table 10) and the revascularised population (Table 11) are provided at the end of this section.
  • ΔAvailable MBS data suggests a significant cost difference (presented below for the benefit of readers), however, it was proposed that the MPS population may have a higher disease burden or higher acuity. If present, the higher disease burden could be requiring more downstream investigations which increases the total average cost over time for MPS. If this is the case, in clinically equivalent populations suitable for both modalities, reduced downstream testing in the MPS cohort may offset the higher initial imaging costs.
  • ΔIt is not possible to determine the disease burden of populations for a direct cost comparison using MBS data. For this reason, the Committee agreed that the cost comparison alone was not sufficient grounds upon which to make a recommendation that either modality should be the preferred stress imaging option where clinically equivalent. The Committee did not consider other factors such as access issues or the radiation burden associated with MPS as a factor in the cost comparison. These considerations are described in Section 4.6.

Cost-comparison analysis

  • ΔThe cost-comparison data included data for the six weeks prior to the trigger and data for the 12 months post-trigger or until revascularisation (PCI or coronary artery bypass graft [CABG]). The following services were included in the cost comparison: stress echo, MPS, ICA, EST, CTCA, ECG or specialist consult (cardiologist or nuclear medicine physician). The cost comparison excluded EST claimed on the same day as the trigger. (The co-claim rate for both modalities is close to 100 per cent.)
  • ΔThe analysis showed that both populations had similar service profiles (Figure 13). Patients who received MPS had higher rates of ICA: 10 per cent for those receiving MPS, and 7 per cent for those receiving stress echo. Patients who received a stress echo had higher rates of CTCA: 5 per cent for those receiving stress echo, and 3 per cent for those receiving MPS. Patients who received MPS had a higher rate of pre-test cardiologist consultations but a lower rate of post-test consultations.
    Figure 13: Service profiles before and after the ‘trigger’ MPS or stress echo
    Figure 13 includes four bar graphs showing service profiles before and after the 'trigger' service, which was the initial MPS or stress echo.
                                        Services before the trigger show that MPS has higher rates of cardiologist consultation (28% vs 22%) and ECG (18% vs 16%) but fewere holter monitors (3% vs 5%).
                                        Post trigger services show that MPS has fewer cardiologist consultations (45% vs 64%), Holters (6% vs 8%), CTCA (3% vs 5%) and EST (6% vs 13%). MPS has higher rates of Nuc Med consults (3% vs 1%), ECG (28% vs 24%), and invasive angio (10% vs 7%).

    Unpublished date of service data for all patients followed in January - March 2015 (Department of Health). The trigger items are 55116, 55117, 61303 and 61307 during period of Jan –Mar 2015 (DOS), services before means 6 weeks before trigger items, services after trigger items are services performed 12 months of trigger items using DOP data up to Aug 2016. Specialist consultations were attributed to specialist groups based on provider Service Related Group classification.

    Figure 14 shows that the average MBS benefit paid for MPS was $513 higher than the average benefit paid for stress echo. This was primarily driven by the difference in rebates between MPS and stress echo. A similar pattern was evident in both the revascularised and non-revascularised patient populations.

    Figure 14: Average MBS benefits by modality, with breakdown
    Figure 14 shows three waterfall charts that compare the average MBS benefits paid per patient over 12 months following a stress echo or MPS. Chart 1 shows the overall difference between stress echo and MPS without breakdown, MPS has a higher average benefits paid by $513. Charts 2 and 3 are broken down into services before the stress echo/MPS, the stress echo/MPS itself, consultations after the stress echo/MPS and other investigations after the stress echo/MPS. Chart 2 shows the population that was not revascularised within 12 months, and shows that MPS has a $511 higher average amount charged per patient. Chart 3 shows the revascularised population for which MPS has a $488 higher average MBS benefits paid per patient. In both charts 2 and 3, the main driver of the difference is the amount charged for the stress echo vs MPS.

    Unpublished date of service data for all patients followed in Q1 2015 (Department of Health).

    The trigger items for SE are 55116, 55117, and MPS are 61303 and 61307 during period of Jan –Mar 2015 (DOS), services before means 6 weeks before trigger items, services after trigger items are services performed 12 months of trigger items using, date of processing data up to Aug 2016.

    Figure 15 and Figure 16 show the difference in the total amount charged (Figure 15) and total patient out-of-pocket costs (Figure 16). The average out-of-pocket cost difference between MPS and stress echo was $5 for revascularised patients and $14 for non-revascularised patients. This difference was primarily due to tests performed after the initial study. The average out-of-pocket cost difference by remoteness (Table 5) revealed a similar difference of $11 to $35.

    Figure 15: Average total charges by modality, with breakdown
    Figure 15 shows three waterfall charts that compare the average amount charged per patient over 12 months following a stress echo or MPS. Chart 1 shows the overall difference between stress echo and MPS without breakdown, MPS has a higher average amount charged by $472. Charts 2 and 3 are broken down into services before the stress echo/MPS, the stress echo/MPS itself, consultations after the stress echo/MPS and other investigations after the stress echo/MPS. Chart 2 shows the population that was not revascularised within 12 months, and shows that MPS has a $468 higher average amount charged per patient. Chart 3 shows the revascularised population for which MPS has a $425 higher average amount charged per patient. In both charts 2 and 3, the main driver of the difference is the amount charged for the stress echo vs MPS.

    1 Includes MBS benefits and patient out-of-pocket expenses Unpublished date of service data for all patients followed in Q1 2015 (Department of Health). The trigger items are SE 55116, 55117, and MPS 61303 and 61307 during period of Jan –Mar 2015 (DOS), services before means 6 weeks before trigger items, services after trigger items are services performed 12 months of trigger items using DOP data up to Aug 2016.

    Figure 16: Average out-of-pocket costs by modality, with breakdown
    Figure 16 shows three waterfall charts that compare the average out-of-pocket costs per patient over 12 months following a stress echo or MPS. Chart 1 shows the overall difference between stress echo and MPS without breakdown, MPS has a lower average out-of-pocket by $41. Charts 2 and 3 are broken down into services before the stress echo/MPS, the stress echo/MPS itself, consultations after the stress echo/MPS and other investigations after the stress echo/MPS. Chart 2 shows the population that was not revascularised within 12 months, and shows that MPS has a $43 lower average out-of-pocket cost. Chart 3 shows the revascularised population for which MPS has a $63 lower average out-of-pocket cost. In both charts 2 and 3, the tests after the stress echo/MPS are the main driver of the difference.

    1 Calculated as total charge minus the MBS benefit paid. Unpublished date of service data for all patients followed in Q1 2015 (Department of Health). The trigger items are for SE 55116, 55117, and MPS 61303 and 61307 during period of Jan –Mar 2015 (DOS), services before means 6 weeks before trigger items, services after trigger items are services performed 12 months of trigger items using DOP data up to Aug 2016.

  • ΔAlthough the average difference was small, concerns were raised about significant variation by geography. However, analysis of the data by state and remoteness did not show any consistent trends that suggest disparity. Bulk-billing rates were relatively flat across remoteness categories (Table 7), with MPS bulk-billed at a higher rate of 92 per cent and stress echo bulk-billed at a rate of 68 per cent. The maximum out-of-pocket cost was higher for MPS ($876.60, excluding seven services with out-of-pocket costs greater than $1,000) than stress echo ($411.55), but this was true for all remoteness areas and all states except the Australian Capital Territory (ACT) (Table 8 and Table 9). When bulk billing was excluded, the average out-of-pocket cost was higher for MPS than stress echo for all remoteness areas, with a national average out-of-pocket cost (excluding bulk billing) of $222.01 for MPS and $103.03 for stress echo (Table 6). Although the out-of-pocket cost for MPS was twice as high as for stress echo, it applied to only 8 per cent of patients, compared to the 32 per cent of stress echo patients who incurred an out-of-pocket charge of $100, on average. The potential impact of any recommendations on patient out-of-pocket costs and bulk-billing rates (and therefore access) must be considered.
  • ΔAs noted above, while the available data suggests a significant cost difference between MPS and stress echo, the lack of clinical information on the populations prevents a complete cost-comparison. The Committee recommended that research should be conducted on the cost-effectiveness of cardiac investigations in the Australian context in order to definitively determine the comparative value of functional imaging modalities.
Table 5: Average out-of-pocket costs by remoteness area*, including bulk-billed services
Remoteness MPS Stress Echo Difference
Major Cities $21.99 $33.99 $12.00
Inner Regional $15.06 $26.29 $11.23
$11.23 $14.35 $34.28 $19.93
Remote $14.69 $35.96 $21.27
Very Remote $7.64 $43.45 $35.81
National Average $18.49 $32.65 $14.16
Table 6: Average out-of-pocket costs by remoteness area*, excluding bulk-billed services
Remoteness MPS Stress Echo Difference
Major Cities $235.99 $111.93 -$124.06
Inner Regional $206.75 $86.42 -$120.33
Outer Regional $210.29 $80.27 -$130.02
Remote $136.28 $94.62 -$41.66
Very Remote $203.39 $140.50 -$62.89
National Average $222.01 $103.03 -$118.99
Table 7: Average bulk-billing rate by remoteness area*
Remoteness MPS Stress Echo
Major Cities 91% 70%
Inner Regional 93% 70%
Outer Regional 93% 57%
Remote 89% 62%
Very Remote 96% 69%
National Average 92% 68%
Table 8: Maximum out-of-pocket costs by remoteness area*
Remoteness area* MPS Stress Echo
Major Cities $876.60 $411.55
Inner Regional $867.60 $402.55
Outer Regional $867.60 $411.55
Remote $618.24 $246.80
Very Remote $528.70 $251.80
National $876.60 $411.55
Table 9: Maximum out-of-pocket costs by state
State MPS Stress Echo
Australian Capital Territory $210.00 $231.55
New South Wales $867.60 $411.55
Northern Territory $417.45 $201.80
Queensland $618.24 $402.55
South Australia $619.45 $231.80
Tasmania $412.45 $138.55
Victoria $876.60 $295.11
Western Australia $665.45 $332.50
Other $212.45 $166.55
National $876.60 $411.55

*Remoteness Area classes are based on ARIA. Reference: ASGS: Volume 5 – Remoteness Structure Australia July 2011, 1270.0.55.005. The patient postcode is linked to the Remoteness Area Concordance file. Unpublished Medicare data for MPS services (61303 and 61307) and SE services (55116 and 55117) during period of Jan –Mar 2015 using date of processing data up to Aug 2016. Department of Health

Table 10: Demographics of total populations, %
Category MPS Stress Echo
Revascularisation Rate
Revascularised 2.5 2.2
Non-revascularised 97.5 97.8
Remoteness
Major Cities 53 70
Inner Regional 27 18
Outer Regional 17 10
Remoteness 3 1
Very Remote 1 0
State
Australian Capital Territory 1 1
New South Wales 37 49
Northern Territory 1 0
Queensland 24 14
South Australia 3 4
Tasmania 2 1
Victoria 26 24
Western Australia 5 6
Other 1 0
Gender
Female 48 42
Male 52 59
Age
0–9 0 0
10–19 0 1
20–29 0 2
30–39 2 4
40–49 6 11
50–59 16 21
60–69 28 31
70–79 31 24
80–89 16 7
90–100 1 0
100–109 0 0
Table 11: Demographics of revascularised population only, %
Category MPS Stress Echo
Revascularisation Rate
Revascularised 100 100
Non-revascularised 0 0
Remoteness
Major Cities 58 69
Inner Regional 27 19
Outer Regional 12 11
Remoteness <2 <2
Very Remote <2 <2
State
Australian Capital Territory 2 1
New South Wales 38 48
Northern Territory <2 <2
Queensland 23 17
South Australia 4 4
Tasmania 2 2
Victoria 25 21
Western Australia 7 6
Other <2 <2
Gender
Female 26 19
Male 74 81
Age
0–9 0 0
10–19 0 0
20–29 0 0
30–39 0 <2
40–49 <2 3
50–59 8 14
60–69 28 35
70–79 43 35
80–89 19 12
90–100 <2 <2
100–109 0 0

For Tables 5- 11 the trigger items are 55116, 55117, 61303 and 61307 during period of Jan –Mar 2015 (DOS), services before means 6 weeks before trigger items, services after trigger items are services performed 12 months of trigger items using DOP data up to Aug 2016.

SE items 55116, 55117, 55122, and 55123. MPS items 61302, 61307, 61654, 61302, 61306, 61651, 61652, and 61653

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