5. General recommendations

Although expert Working Groups reviewed all the current items, several broader themes and general recommendations were made directly by the Committee, with unanimous support.

5.1 Ongoing review of the MBS

Recommendation 7.1

  • ΔImplement an ongoing review process to maintain the alignment of the MBS with contemporary clinical practice.

Recommendation 7.2

  • ΔReview the recommendations relating to cardiac imaging, EST, ICA and PCI 12–24 months after implementation to ensure that the intended outcomes have been achieved, and to inform further revision if necessary.

Rationale

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

  • ΔThe Committee has undertaken considerable work to bring the services within their scope up to date and in alignment with contemporary clinical practice, current evidence and international guidelines. It believes that this will improve the quality of care provided in Australia, have positive impacts on patient outcomes and experience, and improve the value of the MBS for Australians. Previous descriptors were frequently vague, describing the medical services in general terms only. The recommended changes will ensure that the items reflect the latest clinical guidelines, but the MBS will need to be agile in the future, adapting as clinical guidelines evolve. The constant publication of new evidence means that guidelines will be revised and clinical practice will shift, and the MBS needs to be able to change accordingly.
  • ΔThe Committee noted that the Taskforce established a Working Group to consider processes for the ongoing review of the MBS, and it commends them for this undertaking. In principle, the Committee supports recommendations that will allow the MBS to remain evidence-based and in line with clinical best practice.
  • ΔThe Committee noted that the MBS has not undergone a review of this nature before, and that many bold and transformative changes are recommended by this Committee and by other Clinical Committees participating in the Review. In order to assess the success of these recommendations, and to protect against any unintended outcomes, the Committee recommended reviewing several areas 12–24 months after implementation to assess the impact of the changes. The Committee also supports efforts by the Department and academic institutions to monitor the success of various measures, thereby contributing to our understanding of health systems in Australia and more generally.

5.2 Structured request form for cardiac investigations

Recommendation 8

  • ΔCreate structured request forms outlining the minimum requirements for an acceptable cardiac investigation referral.

Rationale

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

  • ΔThe Committee noted that providers (not requestors) are required to ensure that the descriptor of a service is met prior to providing that service. This presents a significant challenge as the referral or request form often does not contain enough information to make an accurate assessment.
  • ΔThe Committee considered creating a structured request form, as is being recommended in other areas of the MBS Review. This ensures both that the requestor has considered all the relevant factors, and that providers have all the relevant information.
  • ΔThe Committee recommended developing a structured request form for cardiac investigations with a threefold purpose:
    • Ensure requestors consider all the relevant information before requesting investigations.
    • Ensure providers have the information needed to verify that the requirements of descriptors are met before performing a service (in line with MBS requirements).
    • Allow providers to consider if the modality requested is the most appropriate for that patient.
  • ΔOnce developed, this request form would constitute the minimum requirements for an acceptable referral for EST, stress echo, MPS, CTCA and echo. A unique form or variant may be required for echo due to the breadth of indications and non-CAD factors that need to be incorporated.
  • ΔThe Committee agreed that a request for a specific procedure or investigation cannot be used as a request for a consultation, as occurs on some ‘tick box’ request forms.
  • ΔThe Committee encourages relevant professional bodies to be actively involved in the development and implementation of this recommendation.

5.3 Co-claiming of consultations with imaging and procedural services

Recommendation 9

  • ΔInclude the following text in the items for echo, stress echo and EST (or make it prominently visible to providers of these services).

In the item descriptor:

  • A consultation may be claimed with this service where (i) the study was not specifically requested by another provider and the decision to perform the study was made during a consultation with the proceduralist on the same day as the study; or (ii) where the provider claiming both services is responsible for the ongoing care of the patient and provides a consultation after the study where clinical management decisions are made.

In the explanatory notes:

  • Discussions of the results, findings or interpretation of a study are reasonably expected to be part of a formal report. Discussion of these findings with a patient does not constitute a consult. Similarly, discussion(s) during the course of a study or to determine the safety or appropriateness of the study is part of the service and should not be claimed as a consult.

Rationale

This recommendation focuses on improving the value of the MBS and is based on the following observations.

  • ΔConsultations are co-claimed with up to 50 per cent of investigation services (Table 12), which the Committee agreed was inappropriately high. The Principle and Rules Committee has considered the co-claiming of consultations and is expected to make a recommendation on this topic. However, given the prevalence of the practice, the Committee felt that it was appropriate to include the above text in these items as a reminder to providers about appropriate use of the MBS. Although including such text in the items is one way to achieve this, it was noted that the Principles and Rules Committee is considering an education and knowledge assurance program for MBS providers, and the Department may choose alternative means for ensuring providers are well aware of when co-claiming consultations is appropriate.
  • ΔThe Committee agreed that co-claiming practices should align with the below explanations (although the Principles and Rules Committee may revise the rules in this regard):
    • If a patient is referred to a cardiologist by any other provider for a specific procedure (e.g., stress echocardiogram, ICA, PCI, electrophysiological studies, pacemaker, structural heart disease intervention), it is not permissible for the cardiologist performing the procedure to charge consultation item numbers related to that procedure, irrespective of whether it is an acute or an elective situation.
    • If a cardiologist self-refers a patient for an elective procedure (such as the tests listed above), it is not permissible to charge a consultation item number on the day of or the day after the procedure, unless the decision to perform the procedure was made during the consultation.
    • If a new patient is admitted to hospital under a specific cardiologist with an acute cardiac condition (e.g., an ACS) and that cardiologist self-refers the patient for a procedure (e.g., ICA/PCI), it is permissible for that cardiologist to charge an initial consultation item number irrespective of whether it is on the same date as the procedure or not.
    • If another provider determined that the procedure was required, a consult is not chargeable unless the provider will also be the primary provider looking after the patient. It is not permissible in any circumstances to charge a consultation item number on the day after the procedure, as this is reasonably considered part of the procedure.
    • If the patient requires an extended hospital stay beyond the day after the procedure, it is permissible for the cardiologist to charge follow-up consultation item numbers during the remainder of the admission, in accordance with the MBS aftercare rules, presuming that he/she continues to be the primary cardiologist looking after the patient.
    • In specific situations—such as for patients travelling from remote areas or for specialist paediatric referrals where guidelines recommend that a consultation be performed prior to an investigation—co-claiming of a consultation may be appropriate. However, clinicians should expect that this will be closely monitored by MBS compliance.
Table 12: Co-claiming of consultations with cardiac investigations
Investigation Co-claim rate
EST 45%
MPS 2%
SE 48%
Echo 23%
ICA 64%

Data is by date of service. Unpublished data from 2014-15 (Department of Health). EST item 11712. SE item 55116. MPS items 61307 Echo items 55113, 55114. ICA items 38218, 38246, and 55925 (excluding episodes co-claimed with PCI 38300, 38303, 38306).

5.4 Heart Team recommendation

Recommendation 10

  • ΔCreate two new items for Heart Team case conferences, as outlined in the descriptors below.

Item HTCC-Convenor

HEART TEAM CASE CONFERENCE CONVENOR – Attendance by a consultant cardiologist/cardio-thoracic surgeon as the principal member of a Heart Team case conference to organise, coordinate and document a meeting which develops a treatment plan where:

  • (a)The benefit of cardiac surgery or percutaneous treatment, including stenting or device implantation is uncertain due to the severity of the underlying cardiac disease, co-morbidities or patient frailty; or
  • (b)The best mode of treatment (surgical, percutaneous or medical therapy alone) is uncertain.

For a cardiac patient with:

  • 1.Stable multi-vessel coronary artery disease considered for coronary artery revascularisation.
  • 2.Complex cardiac disease, including valvular heart disease, structural heart disease and cardiac arrhythmias.

The Heart Team case conference must:

  • 1.Be at least of 10 minutes duration.
  • 2.Be attended by a minimum of 3 Cardiac Specialists (including a Cardiac Surgeon and an Interventional Cardiologist where any interventional procedure may be considered) and other medical or allied health practitioners as deemed appropriate by the convenor. At least 1 of the medical practitioners attending must be a non-interventional cardiologist. Attendance should be face to face, this should be in person where possible but may include video telemedicine where necessary.
  • 3.Be documented in a written report that documents the attendees and summarises the patient’s condition, relevant investigations, the case conference discussion and agreed recommendation(s). A letter or copy of the recommendation must be provided to the patient’s GP if they are not present for the conference.

Item HTCC-Participant

HEART TEAM CASE CONFERENCE PARTICIPANT – Attendance of at least 10 minutes by a medical practitioner (surgeons, specialist or consultant physician in the practice of his or her specialty or a vocationally registered general practitioner, excluding any medical trainees), as a participant in a Heart Team case conference to develop a treatment plan where:

  • (a)The benefit of cardiac surgery or percutaneous treatment, including stenting or device implantation is uncertain due to the severity of the underlying cardiac disease, co-morbidities or patient frailty; or
  • (b)The best mode of treatment (surgical, percutaneous or medical therapy alone) is uncertain.

For a cardiac patient with:

  • 1.Stable multi-vessel coronary artery disease considered for coronary artery revascularisation.
  • 2.Complex cardiac disease, including valvular heart disease, structural heart disease and cardiac arrhythmias.

The Heart Team case conference must:

  • 1.Be at least of 10 minutes duration.
  • 2.Be attended by a minimum of 3 Cardiac Specialists (including a Cardiac Surgeon and an Interventional Cardiologist where any interventional procedure may be considered) and other medical or allied health practitioners as deemed appropriate by the convenor. At least 1 of the medical practitioners attending must be a non-interventional cardiologist. Attendance should be face to face, this should be in person where possible but may include video telemedicine where necessary.
  • 3.Be documented in a written report that documents the attendees and summarises the patient’s condition, relevant investigations, the case conference discussion and agreed recommendation(s). A letter or copy of the recommendation must be provided to the patient’s GP if they are not present for the conference.

Claimable by up to 5 providers per Heart Team conference.

Rationale

  • ΔThe Committee recommended creating two new items for Heart Team consultations in order to increase the likelihood that patients receive the most appropriate treatment for their condition.
  • ΔAlthough guideline-based optimal medical therapy (OMT) and risk factor modification are the foundations for the management of stable CAD, revascularisation may be an appropriate supplemental therapeutic approach for symptom relief purposes where OMT is inadequate or not tolerated. International guidelines (class IC) and published literature are now recommending that for patients with more complex stable CAD, a Heart Team including a non-interventionalist, interventional cardiologist and cardiac surgeon should be involved to discuss the most appropriate treatment options (6,7,35). The Committee recommended that a Heart Team should include a minimum of three providers, and that the items should be claimable by a maximum of six providers including the convenor. The conference should include a GP or non-interventional specialist and, where a decision on revascularisation is required, a cardiac surgeon and interventional cardiologist.
  • ΔThe Committee agreed that there are populations in which PCI or CABG may be the clearly preferred revascularisation option and others where there is clinical equipoise. For example, PCI may be more appropriate for the very elderly, but CABG may be more appropriate for those with a syntax score greater than 22, as the evidence shows that for these patients CABG results in lower rates of MI, death and repeat revascularisation over five years but with higher rates of stroke (35).
  • ΔDespite the existence of international clinical guidelines, variation in practice has been demonstrated overseas (36–38). In Australia, MBS data shows that the ratio of PCI versus CABG is variable across states: patients are twice as likely to have PCI in New South Wales or Western Australia than in South Australia or the Northern Territory (Figure 17) (9).
    Figure 17: Geographical variation in ratio of PCI to CABG
    Figure 17 shows two bar graphs that depict the geographical variation in ratio of PCI to CABG. The first depicts state-based variation and the other rurality based variation. State-based variations shows that NSW, WA and ACT are the highest at 5.1, 5.2 and 5.1 PCI services per CABG respectively. VIC, QLD, SA, TAS and NT are between 2.5 and 4.3.

    Data is by date of service extracted on 20 June 2016. Unpublished data 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. PCI items 38306. CABG items 38497, 38498, 38500, 38501, 38503, and 38504.

  • ΔAlthough there may be multiple factors driving variation in service volumes, individual provider preference may lead to suboptimal treatment decisions (35). Two studies have investigated guideline compliance. A 2010 study found that in a population with Class I indications which recommended CABG, only 53 per cent were recommended for CABG and 34 per cent were recommended for PCI. This compared with 94 per cent compliance when guideline based indications recommended PCI. In patients meeting guideline indications for both PCI and CABG, only 5 per cent received CABG (39). A subsequent study in 2014 found that out of 9,000 patients who received a diagnostic ICA, the test was performed based on “inappropriate” indications 29 per cent of the time, on average (40).
  • ΔPatient preference and level of understanding may also drive this variation. In a recent article, Holmes and Taggart noted that several observational studies have found that patients did not fully understand the likely impacts of their procedures as much as 70–90 per cent of the time (35). This may be due to the health literacy of the population or a lack of information being provided. For example, one study found that 85 per cent of PCI patients and 15 per cent of CABG patients reported that no alternative treatment options were discussed (41). Even when patients are informed that the risks of death or repeat revascularisation are higher with multi-vessel PCI than with CABG, patients prefer PCI (42). The Committee discussed the issue of patient preferences and noted that a patient may simply refuse the recommended treatment option. Where this is likely, the Heart Team could recommend acceptable alternative treatments, with a requirement for documented patient refusal of the primary recommendation. Members noted that in addition to recommending intervention, the Heart Team may be able to support providers who believe the best management is medical therapy or less invasive approaches but where the patient or family is pushing for more aggressive treatment.
  • ΔThe Committee agreed that implementation of a Heart Team item would encourage the adoption of an multidisciplinary team approach in private hospitals, which results in the sharing of ideas and views, as well as improved clinical outcomes through the more frequent use of the most appropriate intervention for each patient. The item is specifically required or available for use as an indication for various other items in these recommendations (such as for PCI in stable CAD), and this will assist with uptake during implementation. Unlike other MTD conference items on the MBS (such as the Cancer Care case conference item 871), the proposed Heart Team item does not require allied health attendance. For this reason, an MBS rebate will be available to remunerate participants—one of the perceived barriers to uptake of similar existing items. The Committee acknowledged that full ramp-up may take time, as with all large-scale behaviour change interventions.
  • ΔMembers acknowledged that the cost of cardiac care is significant, but even if this item is highly utilised, the Committee felt that the net impact would still be positive, due to the effects it would have on provider behaviour. Members agreed that uptake is highly uncertain, with anecdotal evidence suggesting that providers may be reluctant to participate where they feel their preferred treatment option may be challenged. Members agreed that populations where there is clinical equipoise or a high procedure risk should be discussed in a multidisciplinary team setting. It was noted that emerging ICA and PCI recommendations propose Heart Team consultations for certain patient populations. These recommendations are discussed in more detail below.
  • ΔMembers discussed the appropriate interval between Heart Team conferences. It was suggested that there may be highly complex patients where conditions can change significantly, warranting review of a previous decision, or where additional information is required and a return for repeat conference is recommended. For this reason, the Committee did not recommend a restriction on frequency. It was noted that a broad descriptor increases the economic risk of a new service, and that this may result in the change not being recommended by the Taskforce or implemented by the government.
  • ΔThe Committee agreed that face-to-face attendance is desirable. However, telemedicine is important for rural and remote access, and the Committee therefore recommended permitting telemedicine attendance by GPs or offsite providers who bring specific expertise to the conference.
  • ΔThe proposed item does not mirror the item for the TAVI Heart Team currently under consideration by the MSAC as that item will include specific requirements, such as the involvement of a TAVI coordinator.

5.5 Documentation of compliance with prescribed indications

Recommendation 11

  • ΔFor cardiac procedures and investigations with specific indications, require documentation in a written report outlining how the requirements in the descriptor (and the explanatory notes, where relevant) were met.

Rationale

  • ΔAlthough documentation and the provision of reports is considered standard practice, the Committee agreed that in order for the recommended changes to be easily auditable, it would be valuable to reinforce the requirement for documentation outlining how the indication requirements in the descriptor were met. This recommendation has been applied to the relevant descriptors throughout the report.
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